Association between abdominal surgical incision type and midline intraperitoneal adhesion occurrence, findings from laparoscopic evaluation in a low-resource setting; a retrospective cohort of laparoscopic evaluations.

Retrospective cohort of laparoscopic evaluations. The Fertility and Reproductive Medicine unit in the department of Obstetrics and Gynaecology, of the Babcock University Teaching Hospital (BUTH). The BUTH is in the Ikenne Local Government Area (LGA) of Ogun state, southwestern Nigeria. It is a private Teaching Hospital, owned by the Seventh Day Adventist Hospital, but has been public since inception, providing care for people in Ogun state and neighbouring states. The study involved data collection from all cases of laparoscopic surgeries done on gynaecological patients between January 2016 and December 2025 (10 years). A team comprising three investigators at the level of senior registrar/consultant was involved in the extraction of data with the aid of a proforma, designed by the authors. The sources of data included case files, electronic records, surgical booking registers, admission and discharge registers, operating theatre registers and operation notes. Laparoscopy was done in all cases with a gynaecological endoscopic surgeon leading the team, peritoneal entry was with the aid of a Veress needle, and the umbilical region was used for entry in most cases, while the Palmer’s point entry was used when abdominal scar precluded umbilical entry. Insufflation was done with carbon dioxide using a pre-set pressure of 15mmHg for all diagnostic cases and 18-20mmHg, for all the operative procedures. The reported adhesions were scored using a combination of location within the nine regions and grades according the peritoneal adhesion index (PAI) by Coccolini et al. 2013 [ 10 ]. The Coccolini system considers all the nine regions of the abdominal cavity; bowel to bowel adhesions was also considered a region. The nine regions of the peritoneal cavity were labeled A-J, running clockwise from the right hypochondrion, terminating in the umbilical region as I, while bowel to bowel adhesion was labeled J [ 10 ]. The adhesion grade was scored thus; 0- No adhesion 1- Filmy adhesions, requiring blunt dissection 2- Strong adhesions requiring sharp dissection 3- Very strong vascularized adhesions that required sharp dissection, and in which damage was hardly preventable 0- No adhesion 1- Filmy adhesions, requiring blunt dissection 2- Strong adhesions requiring sharp dissection 3- Very strong vascularized adhesions that required sharp dissection, and in which damage was hardly preventable An adhesion grade was assigned to each of the nine abdominal regions where an adhesion was reported, based on descriptions in the operation notes. Bowel-to-bowel adhesion was also graded. In addition, bowel to omentum was considered as bowel-to-bowel adhesion and labeled region ‘J’. The grades for each region where an adhesion was reported were then summed up to derive the PAI score as described by Coccolini et al. (Fig.  1 ). Higher PAI score indicates greater severity of peritoneal adhesions. Fig. 1 Description of the derivation of the PAI scores, schematic diagram of the anterior abdominal wall showing the re-labeled nine regions Description of the derivation of the PAI scores, schematic diagram of the anterior abdominal wall showing the re-labeled nine regions The midline regions are the epigastrium, umbilical and the suprapubic region, labeled as ‘B’, I’, and ‘F’, respectively (Fig.  1 ). Patients with adhesions in this region are those considered to be at increased risk for entry-related injuries in subsequent surgeries. Adhesions described as mild, or flimsy, in the operation records were considered as filmy and graded I using the Coccolini classification. Adhesions reported in the operation notes as moderate, strong or in which sharp dissection was used were considered as strong and graded II, while adhesions described as severe or dense or in regions or aspects described as ‘‘frozen’’ or in which dissection could not be done, or dissection resulted in injury were graded as III. The midline regions were considered as the ‘epigastrium’, ‘central’ and ‘pelvis’, which are also denoted as ‘B’, ‘I’ and ‘F’ in the Coccolini et al. 2013 [ 10 ] grading system and which correspond to the epigastric, the umbilical and the suprapubic regions respectively (Fig. 1 ). Inflammatory conditions are those conditions whose diagnosis is associated with, caused by or result in inflammation or infection [ 20 , 21 ], that are either diagnosed preoperatively or found during laparoscopy. Conditions considered as inflammatory or infective in this study include (as diagnosed) appendicitis, chronic pelvic pain, complicated ovarian cyst, endometriosis, endometrial osseus metaplasia, hydrosalpinx, pelvic inflammatory disease, pelvic abscess, and entrapped peritoneal drain. The data of patients with ‘adhesion’ as their only findings were not classified into inflammatory or non-inflammatory. This sub-group had their data excluded from the corresponding predictor cells because of the potential duplication and confounding effect. The conditions considered as non-inflammatory in this study include abnormal uterine bleeding, amenorrhea, ectopic pregnancy, infertility, polycystic ovarian syndrome (PCOS), gestational trophoblastic disease, uterine fibroid, pelvic organ prolapse, abdominal or pelvic tumour and missing intrauterine contraceptive device (IUCD) [ 20 – 22 ]. Data of individuals with diagnosis of ‘normal’ peritoneal findings, uncomplicated ovarian cysts and ‘streak ovaries’ at laparoscopy were also classified as non-inflammatory. Adapted from; Coccolini et al. World Journal of Emergency Surgery 2013, 8:6. http://www.wjes.org/content/8/1/6 . Data was analyzed using SPSS version 25.0 (SPSS Inc., Chicago, IL). Numerical data were expressed as mean ± standard deviation (SD). Bivariate analysis included the use of the independent t-test to compare means and Chi-square test to compare categorical variables. Binary logistic regression was used to determine the factors associated with midline adhesion finding during laparoscopy. The level of statistical significance was set at p -value of < 0.05. Ethical clearance for the research was obtained from the Babcock University Health Research and Ethics Committee, No: BUHREC 015/26NB/88. Permission was obtained from the BUTH records department, operating theatre department and the gynaecological wards for the use of patients’ hospital records. This study was conducted in accordance with the declaration of Helsinki, although consent was not required, all data collected were completely anonymized and kept safely in a password protected computer.

A total of 296 laparoscopic gynaecological evaluations done within the index period were included in the analysis. Adhesions were found in 96/296 of these laparoscopies giving a prevalence of 32.4%, with majority 80/96 (83.3%) of the adhesions found in the midline regions. More than half of the adhesions were also observed to be attached to the anterior abdominal wall (Fig.  2 ). Fig. 2 Prevalence of adhesions in patients undergoing laparoscopy Prevalence of adhesions in patients undergoing laparoscopy The Table  1 , reveals that while age ( p  = 0.378), parity ( p  = 0.987), BMI ( p  = 0.158) and pre-operative diagnosis ( p  = 0.407) were not significantly different between individuals who had adhesions and those without adhesions, previous peritoneal surgery ( p  = 0.004, ARR = 40.274, 16.470-64.767) was the most important risk factor associated with adhesion formation. Previous history of abortion ( p  = 0.044) was also associated with adhesion formation, but with an adjusted relative risk 0.261. Surgeries involving the uterus or adnexa ( p  = 0.883) and the type of abdominal incision ( p  = 0.387), were however, not significantly associated with adhesion formation. The proportions of inflammatory conditions observed at laparoscopy were also significantly higher among patients with peritoneal adhesions( p  < 0.001). Table 1 Determinants of occurrence of peritoneal adhesions Factor Occurrence of peritoneal adhesion RR (95% CI) * p -value No Yes Age (years)  < 30 years ( n  = 76) 53 (59.7%) 23 (30.3%) NS 0.378  ≥ 30 years ( n  = 220) 147 (66.8%) 73 (30.2%) Parity  Nullipara ( n  = 195) 137 (70.3%) 58 (29.7%) NS 0.987  ≥ para1 ( n  = 101) 63 (62.4%) 38 (37.6%) Previous abortion CRR = 2.719  No ( n  = 202) 151 (74.8%) 51 (25.2%) ARR = 0.261 0.044  Yes ( n  = 94) 49 (52.1%) 45 (47.9%) 0.071–0.962 Previous Peritoneal surgery CRR = 32.660  No ( n  = 209) 184(88.0%) 25 (12.0%) ARR = 40.274 0.004  Yes ( n  = 87) 16 (18.4%) 71 (81.6%) 16.470-64.767 Previous surgery involving uterus or adnexa  No ( n  = 21) 4 (19.0%) 17 (81.0%) NS 0.883  Yes ( n  = 66) 12 (18.2%) 54 (81.8%) Incision type ( n  = 87)  Non midline ( n  = 58) 13 (22.4%) 45 (77.6%) NS 0.387  Midline ( n  = 29) 3 (10.3%) 26 (89.7%) BMI  <25 kg/m² ( n  = 123) 82 (66.7%) 41(33.3%) NS 0.158  ≥25 kg/m² ( n  = 173) 118 (68.2%) 55 (31.8%) Pre-operative diagnosis/indication  Non-inflammatory ( n  = 204) 140 (68.6%) 64 (31.4%) NS 0.407  Inflammatory ( n  = 92) 60 (65.2%) 32 (34.8%) a Main findings at laparoscopy a Occurrence of adhesion No ( n  = 200) Yes ( n  = 58)  Non-inflammatory ( n  = 194) 162 (83.5%) 32 (16.5%) RR = 8.526 b <0.001  Inflammatory ( n  = 102) 38 (37.3%) 64 (62.7%) 4.909–14.810 *Multivariable logistic regression statistic a n =38 individuals with ‘adhesions’ as only finding were not classified into inflammatory/non-inflammatory b Chi-square test statistics Determinants of occurrence of peritoneal adhesions *Multivariable logistic regression statistic a n =38 individuals with ‘adhesions’ as only finding were not classified into inflammatory/non-inflammatory b Chi-square test statistics Table  2 shows the severity of adhesions as depicted by the PAI scores of the different peritoneal surgeries. Exploratory laparotomy (PAI = 10.80 ± 2.864), myomectomy (PAI = 10.89 ± 3.705), salpingectomy (PAI = 11.00 ± 5.657) and ovarian cystectomy (PAI = 10.67 ± 2.309) were associated with the most severe adhesions, while appendicectomy (PAI = 6.17 ± 3.738) and caesarean section (PAI = 7.47 ± 3.338) had the least PAI scores. Laparoscopy (PAI = 8.33 ± 4.041) was observed to have a somewhat higher PAI score than caesarean section and appendicectomy. Table 2 Specific previous abdominal surgery, their PAI scores and adhesion finding rates Specific previous peritoneal surgery ( n  = 87) Occurrence of peritoneal adhesion PAI score No ( n  = 16) *Yes ( n  = 71) Not involving uterus and adnexa  Appendicectomy ( n  = 16) 4 (25%) 12 (75%) 6.17 ± 3.738  Exploratory laparotomy ( n  = 5) 0 5 (100%) 10.80 ± 2.864 Involving uterus and adnexa  Hysterectomy ( n  = 1) 0 1 (100%) 10.00  Caesarean section ( n  = 20) 3 (15%) 17 (85%) 7.47 ± 3.338  Laparoscopy ( n  = 5) 2 (40%) 3 (60%) 8.33  Myomectomy ( n  = 35) 7 (20%) 28 (80%) 10.89 ± 3.705  Salpingectomy ( n  = 2) 0 2 (100%) 11.00  Ovarian cystectomy ( n  = 3) 0 3 (100%) 10.67 *PAI scores were calculated only for individuals whose data were ‘yes’ to previous specific peritoneal surgery Specific previous abdominal surgery, their PAI scores and adhesion finding rates *PAI scores were calculated only for individuals whose data were ‘yes’ to previous specific peritoneal surgery Table  3 , shows that the adhesions found in the midline region were significantly associated with history of previous peritoneal surgeries ( p  < 0.001, ARR = 10.279, 3.111–34.579). BMI ( p  = 0.272) and main laparoscopy findings ( p  = 0.418) were, however, not statistically different between individuals who developed adhesions in the midline and those who did not. Surgeries involving the uterus and adnexa ( p  = 0.997), incision type ( p  = 0.998), and pre-operative diagnosis ( p  = 0.998) were not significantly associated with occurrence of adhesions in the midline regions. Table 3 Determinants of occurrence of peritoneal adhesions in the midline regions Factor Presence of adhesions in the midline RR (95% CI) * p -value No ( n  = 16) Yes ( n  = 80) Previous Peritoneal surgery CRR = 10.371  No ( n  = 25) 11 (44.0%) 14 (56.0%) ARR = 10.279 < 0.001  Yes ( n  = 71) 5 (7.0%) 66 (93.0%) 3.111–34.579 Previous abortion  No ( n  = 51) 10 (19.6%) 41 (80.4%) NS 0.434  Yes ( n  = 45) 6 (13.3%) 39 (86.7%) Previous surgery involving uterus and adnexa ( n  = 71)  No ( n  = 17) 5 (29.4%) 12 (70.6%) NS 0.997  Yes ( n  = 54) 0(0) 54 (100%) Incision type ( n  = 71)  Non midline ( n  = 45) 5 (11.1%) 40 (88.9%) NS 0.998  Midline ( n  = 26) 0(0) 26 (100%) BMI  <25 kg/m² ( n  = 41) 9 (22.0%) 32 (78.0%) NS 0.272  ≥25 kg/m² ( n  = 55) 7 (12.7%) 48 (87.3%) Pre-operative diagnosis/indication  Non-inflammatory ( n  = 64) 10 (15.6%) 54 (84.4%) NS 0.998  Inflammatory ( n  = 32) 6 (18.8%) 26 (81.2%) a Main findings at laparoscopy Adhesion in the midline No ( n  = 12) Yes ( n  = 46)  Non-inflammatory ( n  = 32) 7 (21.9%) 25 (78.1%) NS 0.666  Inflammatory ( n  = 26) 5 (19.2%) 21 (80.8%) *Multivariable logistic regression statistics a n =38 individuals with ‘adhesions’ as only finding were not classified into inflammatory/non-inflammatory Determinants of occurrence of peritoneal adhesions in the midline regions *Multivariable logistic regression statistics a n =38 individuals with ‘adhesions’ as only finding were not classified into inflammatory/non-inflammatory Table  4 highlights the determinants of attachment of adhesion to the anterior abdominal wall, using the multivariable logistic regression model. The rate of attachment of peritoneal adhesions to the anterior abdominal wall was not significantly different between individuals with previous peritoneal surgery ( p  = 0.113), surgeries involving the uterus/adnexa ( p  = 0.327), incision type ( p  = 0.974), preoperative diagnosis ( p  = 0.246), inflammatory conditions as main findings at laparoscopy ( p  = 0.823) or adhesion presence in the midline regions ( p  = 0.999). Table 4 Determinants of peritoneal adhesion attachment to the anterior abdominal wall Factor Attachment to the anterior abdominal wall RR (95% CI) * p -value No Yes Previous Peritoneal surgery  No ( n  = 25) 15 (60.0%) 10 (40.0%) NS 0.113  Yes ( n  = 71) 29 (40.8%) 42 (59.2%) Previous abortion  No ( n  = 51) 25 (49.0%) 26 (51.0%) NS 0.393  Yes ( n  = 45) 19 (42.2%) 26 (57.8%) Incision type ( n  = 71)  Non midline ( n  = 45) 20 (44.4%) 25 (55.6%) NS 0.974  Midline ( n  = 26) 9 (34.6%) 17 (65.4%) Previous surgery involving uterus and adnexa ( n  = 71)  No ( n  = 17) 7 (41.2%) 10 (58.8%) NS 0.327  Yes ( n  = 54) 22 (40.7%) 32 (59.3%) BMI  <25 kg/m² ( n  = 41) 21 (51.2%) 20 (48.8%) NS 0.402  ≥25 kg/m² ( n  = 55) 23 (41.8%) 32 (58.2%) Pre-operative diagnosis/indication  Non inflammatory ( n  = 64) 29 (45.3%) 35 (54.7%) NS 0.246  Inflammatory ( n  = 32) 15 (46.9%) 17 (53.1%) a Main findings at laparoscopy  Non-inflammatory ( n  = 32) 18 (50.2%) 14 (43.8%) NS 0.823  Inflammatory ( n  = 26) 11 (42.3%) 15 (57.7%) Adhesion in midline region  No ( n  = 16) 14 (87.5%) 2 (12.5%) NS 0.999  Yes ( n  = 80) 30 (37.5%) 50 (62.5%) *Multivariable logistic regression statistics a n =38 individuals with ‘adhesions’ as only finding were not classified into inflammatory/non-inflammatory Determinants of peritoneal adhesion attachment to the anterior abdominal wall *Multivariable logistic regression statistics a n =38 individuals with ‘adhesions’ as only finding were not classified into inflammatory/non-inflammatory Table  5 depicts the findings of sub-group multivariable logistic regression analysis of adhesion attachment to the midline anterior abdominal wall regions and reveals that there was no association between these regions and the risk of attachment to the anterior abdominal wall. Epigastric ( p  = 0.778), umbilical ( p  = 0.345), suprapubic ( p  = 0.999), combined umbilical and suprapubic ( p  = 0.874) and all three midline regions ( p  = 0.383). Table 5 Relationship between adhesions in specific midline regions and attachment to the anterior abdominal wall Midline region Attachment to the anterior abdominal wall RR (95%CI) * p -value Epigastric adhesions No Yes  No ( n  = 82) 41 (50.0%) 41 (50.0%) NS 0.778  Yes ( n  = 14) 3 (21.4%) 11 (78.6%) Umbilical(central) adhesions  No ( n  = 40) 24 (60.0%) 16 (40.0%) NS 0.345  Yes ( n  = 56) 20 (35.7%) 36 (64.3%) Suprapubic (pelvic)  No ( n  = 17) 15 (88.2%) 2 (11.8%) NS 0.999  Yes ( n  = 79) 29 (36.7%) 50 (63.3%) Suprapubic + Umbilical  No ( n  = 40) 24 (60.0%) 16 (40.0%) NS 0.874  Yes ( n  = 56) 20 (35.7%) 36 (64.3%) Suprapubic + Umbilical + Epigastric  No ( n  = 86) 43 (50.0%) 43 (50.0%) NS 0.383  Yes ( n  = 10) 1 (10.0%) 9 (90.0%) *Multivariable logistic regression statistics Relationship between adhesions in specific midline regions and attachment to the anterior abdominal wall *Multivariable logistic regression statistics Table  6 , shows that the major factors determining the occurrence, spread and locations of adhesions, also had significantly greater adhesion severity, as seen in their higher PAI scores, these factors include; previous peritoneal surgery (PAI = 9.14 ± 3.93, p  = 0.008), adhesions in the midline region (PAI = 9.48 ± 3.57, p  < 0.001) and attachment to the anterior abdominal wall (PAI = 10.52 ± 3.450, p  < 0.001). There was no statistically significant relationship between PAI score and surgery involving uterus/adnexa ( p  = 0.064), incision type ( p  = 0.202), preoperative diagnosis ( p  = 0.228) and main findings at laparoscopy ( p  = 0.211). The laparoscopic adhesiolysis rates were not different between adhesions observed in the midline and those found elsewhere ( p  = 0.410). Table 6 Comparison of severity between the determinants and outcomes of peritoneal adhesions Parameter PAI score Median (IQR) * p -value Previous Peritoneal surgery ( n  = 71) 9.00 (6) 0.008 Previous surgery involving uterus/adnexa ( n  = 54) 10.00 (5) 0.064 Incision type-midline ( n  = 26) 11.00 (5) 0.202 Preoperative diagnosis-inflammatory ( n  = 32) 8.50 (6) 0.228 Main findings at laparoscopy-inflammatory condition ( n  = 26) 8.50 (6) 0.689 Adhesion in midline region ( n  = 80) 9.50 (5) < 0.001 Attachment to the anterior abdominal wall ( n  = 52) 11.00 (5) < 0.001 Laparoscopic adhesiolysis Adhesion in midline region No Yes  No ( n  = 16) 5 (31.2%) 11 (68.8%) a 0.410  Yes ( n  = 80) 36 (45.0%) 44 (55.0%) *Mann-Whitney U test p -value a Fisher’s exact test p -value Comparison of severity between the determinants and outcomes of peritoneal adhesions *Mann-Whitney U test p -value a Fisher’s exact test p -value

There is a considerable risk associated with performing surgeries via the abdominal route on individuals with midline peritoneal adhesions either in patients who have had surgeries in the same site previously or from other adhesiogenic causes [ 1 – 3 ]. The difficulty with peritoneal access when the anterior abdominal wall is involved and challenges with access to surgical target organs, apart from increasing operating time also significantly raises the likelihood of injury to abdominal viscera, such as bowel, bladder and ureters. The longer time required to gain peritoneal access may also increase the risk of blood transfusion, thromboembolism and infectious morbidity [ 3 – 6 ]. Abdominal incisions are guided by several factors, including the type and extent of surgery, the location of the target organ or viscus, the route of surgery (whether laparoscopic or open), and the patient’s comorbidities. It is however notable that most incisions on the abdomen are around the midline and involve mostly the umbilical and suprapubic regions, due to the greater distance of these sites from the intraabdominal viscera and great vessels to prevent injury to them, during abdominal entry. In addition the midline contains the linea-alba, a condensation of fibrous tissue formed from the rectus sheath meeting in the midline, incisions here help to limit blood loss associated with surgery [ 1 , 5 , 7 ]. Unfortunately adhesions often form at the peritoneal surfaces of these sites after surgery, making a repeat access through these points a daunting task for surgeons and a risk of injury to structures which may be included in the adhesive mass [ 5 ]. The contents of the peritoneal adhesions in the midline whether related to previous incisions or not, often include omentum, bowel, intrabdominal displaced viscera like the bladder, uterus and ovary which may be inadvertently injured at entry [ 5 , 7 , 8 ]. Adhesion preventive measures for the primary surgeries and alternative entry techniques for the later surgeries are the major safety mechanisms employed in preventing injury during repeat abdominal surgeries or surgery in patients with likelihood of peritoneal adhesions, from conditions such as endometriosis, inflammatory conditions and diabetes mellitus [ 1 , 9 ]. Although adhesion preventive barriers such as interceed, Gore Tex, Seprafilm etc. and pharmacological agents have been be used, to prevent adhesions, there is presently no best method with high level of recommendation [ 1 , 9 , 10 ]. In addition, the physical and pharmacological agents are not in widespread use in low resource settings were open abdominal procedures are common, with open techniques more likely to produce adhesions and where infectious morbidity a risk factor for adhesion is commoner. Even in settings where these adhesion prevention barriers abound, peritoneal adhesions are also reported and surgery in patients with adhesions may be inevitable in many instances [ 5 , 11 ]. Peritoneal adhesions have been reported in individuals who have never undergone a surgical procedure and common risk factors of this occurrence include pelvic inflammatory disease, endometriosis and specific visceral inflammatory or infective conditions such complicated appendicitis, cholecystitis, perforated peptic ulcer and abortion [ 1 , 5 , 12 , 13 ]. A high prevalence rate ranging from 63% to 97% has been consistently reported for adhesion complications of all previous peritoneal surgeries, and 60–90% prevalence rate reported for peritoneal adhesion complications of gynaecological operative procedures [ 11 , 13 , 14 ]. Thus, studies have consistently linked adhesion formation to a history of previous peritoneal surgery, with comparatively higher severity of adhesions in individuals with a history of previous peritoneal surgeries than in those with no such history [ 1 , 7 , 12 , 15 ]. A study from the Democratic Republic of Congo, a nearby central African, country, reports a prevalence rate of 65% peritoneal adhesion rate observed during diagnostic laparoscopy in patients who have previously undergone surgery involving the peritoneal cavity [ 7 ]. Although myomectomy has been reported as the surgery linked with the highest prevalence and severity of peritoneal adhesion [ 12 , 16 ]. It is however unclear if post-myomectomy adhesions are mostly central and portend great entry risk for repeat surgeries involving the abdomen. There is presently no report of any study delineating the prevalence and severity of midline adhesion where incisions and abdominal entry are most done for surgeries involving the abdomen. Entry related injury is of greater importance in abdominal surgeries where blind entry is often the case and the entry point is usually sharp and wider, leaving the risk of bowel, omental or other visceral injury which may be overt or covert. Abdominal surgeries are still the commonest route in low resource settings of the world with a disproportionately lower uptake of laparoscopy, which has safer, better abdominal entry potential and lower risk of injury [ 2 , 3 , 17 ]. The fact that peritoneal adhesions are difficult to pick by most imaging techniques [ 18 ], also necessitates increased efforts to reasonably predict this risk of mid-line adhesion and entry related injury [ 10 ]. These imaging modalities are in limited use in low resource settings of the world, where most of the abdominal surgeries are done by the open technique. The cost of procuring these equipment, the limited capability for maintenance, fluctuating electricity power supply, limit the widespread use of these modalities in these settings. Data, guiding the prevalence, the risks and the surgeries associated mostly with the occurrence of midline peritoneal adhesion may inform increased measures to ensure safety of repeat surgeries on individuals with increased risk of these adhesions and would further strengthen the evidence base for an increase in the uptake of safer surgical route like laparoscopy and safer alternative abdominal entry techniques, especially in low resource settings. Laparoscopic entry in the settings of adhesion are safer because of the ability to use other sites such as the Palmer’s point, Jain point, higher umbilical entry and coupled with the fact that smaller entry points are involved and the advantage of peritoneal insufflation which gives a better view [ 1 , 2 , 5 , 19 ]. A retrospective design was chosen for this study because of the ethical issues inherent in making incisions just to observe the adhesion risks. This study therefore aimed to ascertain the determinants of occurrence of midline peritoneal adhesion and the association between adhesion findings and previous abdominal incisions in gynecological patients who underwent laparoscopic evaluation, in a low resource setting of southwestern Nigeria.

This study demonstrates that previous peritoneal surgery, irrespective of uterine or adnexal involvement, was associated with increased risk for intraperitoneal adhesion formation. The incision type and the depth of surgery, were, however, not significantly associated with the risk of adhesion formation, location of adhesion in the midline or attachment to the anterior abdominal wall, suggesting an interplay of other operative surgical considerations. This buttresses the roles of surgical techniques in adhesion development, the need for adhesion-preventive strategies for primary surgeries and careful planning of repeat surgeries.

This study identified previous peritoneal surgery as the strongest predictor of adhesion formation (ARR = 40.27), consistent with established evidence that surgical trauma to the peritoneum initiates a cascade of inflammation, fibrin deposition, and impaired fibrinolysis, culminating in adhesion formation [ 11 , 13 , 14 ]. The peritoneal adhesion prevalence of 32.4% observed in this study, however, is much lower than the global rate of 67–93%, which has remained relatively constant, defying preventive measures [ 2 , 23 ]. This prevalence also contrasts reported rates observed by Guven et al. (44.1%) [ 3 ] and Al Husban et al. (45.3%) [ 8 ] but is close to the 35.5% found by Brill et al. [ 24 ], found during laparoscopy for individuals with history of previous laparotomy. The differences in prevalence may be attributed to variations in patient selection and differences in prior surgical exposures, as studies with higher prevalence often include a greater proportion of patients with previous pelvic surgery [ 25 ]. The prevalence in our study however contrasts the higher 41.7% observed by Nzau-Ngoma et al. in a similar population among native sub-Saharan Africans in the Democratic Republic of Congo [ 7 ], where laparoscopies were done in 119 individuals including those without prior peritoneal surgeries. Previous abortion was also a significant predictor of adhesion formation, although with low relative risk. This may be related to subclinical pelvic infection or instrumentation-related endometrial and tubal trauma, which can promote inflammatory processes and subsequent adhesion formation. Similar associations have been suggested in gynecological populations where pelvic inflammation and infections complicated instrumentation for induced abortion [ 15 , 26 , 27 ]. The association between inflammatory conditions observed at laparoscopy and the occurrence of peritoneal adhesions in this study largely supports the above finding and corroborates the role of inflammation as a well-recognized driver of adhesion formation, as it disrupts the balance between fibrin deposition and degradation, favoring fibrous band formation [ 11 , 14 ]. Age, parity, BMI, and indication for laparoscopy were, however, not significantly associated with adhesion formation. The foregoing suggests that adhesion development is more strongly influenced by direct peritoneal insult and inflammatory processes than by baseline patient characteristics, a finding which is consistent with previous reports [ 5 , 6 ]. In addition, specific prior surgeries such as exploratory laparotomy, myomectomy, salpingectomy, ovarian cystectomy, and hysterectomy—were associated with the highest adhesion severities as indicated in their relatively higher PAI scores. This aligns with previous studies indicating that uterine surgeries, particularly those involving incision and repair of the myometrium, predispose to adhesion formation due to tissue ischemia, bleeding, and healing responses [ 7 , 12 , 14 , 15 ]. They typically involve extensive handling of peritoneal tissue and tissue dissection, increasing the likelihood of adhesion formation. Open abdominal procedures are generally associated with higher adhesion burdens compared to less invasive approaches like laparoscopy [ 2 , 5 ]. The lower degree of peritoneal invasion above may also explain the finding of relatively lower PAI scores for caesarean section and appendicectomy. Laparoscopy was however observed, to have a higher PAI score than caesarean section and appendicectomy. This finding may be explained by the fact that this study was conducted among a cohort of women with gynaecological conditions, and mostly for infertility, with variabilities in pathologies, which may also be adhesion risks and indications for previous laparoscopies. Women, with infertility, may have a variable range of occult infective and inflammatory lesions which are risks for both infertility and adhesion formation [ 28 ]. Laparoscopy has been well established and documented to have less risk for peritoneal adhesions than open surgery [ 2 , 3 , 5 , 6 ]. Although a strong association was observed between a history of previous peritoneal surgery and adhesion location in the midline regions, there was no significant association between uterine/adnexal surgery and midline adhesion formation, suggesting that factors, different from the depth of surgery and inflammatory characteristics of target organs, may be responsible for the midline location of peritoneal adhesions, although depth and organ/tissue characteristics are recognized risk factors for midline location of adhesions [ 5 , 6 , 11 , 14 ]. Meticulous tissue handling and dissection, avoidance of unnecessary blunt tissue trauma, barrier methods and laparoscopy are important measures that prevent adhesions in the midline [ 1 , 9 ]. Incision type was, however, not significantly associated with increased risk for adhesion formation; midline incisions especially provide greater peritoneal exposure, minimal bleeding, less nerve injury and wider range of manipulation. This contrasts findings from some studies that suggested midline incisions as risk factors for adhesions in the midline, recommending transverse laparotomy incisions instead, as preventive measures [ 24 , 29 , 30 ]. Incision type was also not significantly related to findings of adhesion in the midline or attachment of adhesions to the anterior abdominal wall. This suggests other mechanisms as risk factors for the occurrence, severity and distribution of post-operative peritoneal adhesions. The design and the single study site-based nature of our study may make it underpowered to detect a difference in midline adhesion occurrence between incision types, larger prospective studies are therefore suggested. The finding of significantly higher PAI scores among patients with midline incisions and patients with adhesions attached to the anterior abdominal wall suggests that adhesion ‘severity’ was a major determinant of midline adhesion location and involvement of the anterior abdominal wall. Adhesions in these locations increase the risk of iatrogenic injuries related to peritoneal entry during repeat surgeries in these individuals. Severe adhesions have been linked to increased risk of bowel obstruction, infertility, and prolonged operative time [ 4 , 5 ]. The finding in this present study, that laparoscopic adhesion resection rates were not different between the midline regions (where most primary entry incisions pass) and other regions also implies increased risk for visceral injury during repeat surgeries. Attachment to the anterior abdominal wall should thus be anticipated whenever adhesions in the midline are suspected. Prevention of adhesion therefore remains a key consideration during primary peritoneal surgeries, especially involving laparotomies. Meticulous surgical techniques have been suggested as the best preventive measure for adhesions [ 31 ]. This is especially important in sub-Saharan African settings where most surgeries are done using the open approach. Therefore, meticulous surgical technique, minimizing tissue trauma, and the use of adhesion prevention barriers cannot be overemphasized [ 1 , 9 , 29 ]. Furthermore, the observed association of abdominal wall attachment with umbilical and suprapubic adhesions, where most incisions are made, further emphasizes the importance of safe entry techniques in patients with prior surgery. Findings from earlier studies support the use of alternative entry points or open entry techniques for laparoscopy in such patients to minimize entry-related complications [ 17 ]. A major strength of this study is the use of diagnostic laparoscopy, which allows for direct visualization and objective assessment of adhesions, which is superior to imaging modalities that may underestimate adhesion presence [ 18 ]. Additionally, the use of the validated PAI scoring system enhances the reproducibility and comparability of findings. However, the study is limited by its single-centre location and the fact that the population consisted of participants who underwent laparoscopic evaluation for gynaecological conditions, with variable range of lesions which may be risk factors for adhesions. In addition, the retrospective reconstruction of the PAI grading has potential to introduce observer bias. Despite these limitations, the study provides valuable insight into adhesion patterns in a typical low-resource clinical context, where open abdominal surgery remains common. Further prospective studies would be required to enhance the strategies aimed at limiting post-operative peritoneal adhesions.