Effect of Surgicel Application on Adhesion Formation to the Uterine Scar Following Cesarean Section ()
1. Introduction
Cesarean section (CS) is among the most frequently performed obstetric procedures worldwide. Despite its safety, postoperative adhesions remain a significant long-term complication, affecting fertility, causing chronic pelvic pain, and complicating future abdominal surgeries [1]. Adhesions arise from normal peritoneal wound healing involving inflammation, fibroblast activation, and collagen deposition [2].
Hemostatic agents such as Surgicel (oxidized regenerated cellulose, ORC) are commonly used to control bleeding during surgery. Surgicel acts as a physical matrix promoting platelet aggregation and clot formation, and it is fully biodegradable. However, animal and human studies suggest that ORC may cause local inflammation and fibrosis, potentially promoting adhesion formation [3] [4].
The literature remains inconclusive: some studies report increased adhesion risk with Surgicel [5] [6], while others find no significant association [7] [8]. Given the global increase in cesarean deliveries and the lack of focused data on uterine scar adhesions, this study aims to evaluate the effect of Surgicel on adhesion incidence, extent, and tenacity at the uterine incision site after cesarean section.
2. Materials and Methods
2.1. Study Design
This prospective cohort study was performed at the Department of Obstetrics and Gynecology, Saudi National Hospital, Makkah, between January 2024 and October 2024.
2.2. Ethical Considerations
The study was approved by the Saudi National Hospital Research Ethics Committee (Approval No. SNH/OBG/2024/011). All participants provided written informed consent prior to inclusion.
2.3. Participants
Women aged 18 - 40 years scheduled for elective or emergency CS were eligible. Exclusion criteria included previous pelvic inflammatory disease, prior pelvic radiation, coagulation disorders, or known allergy to ORC materials.
Participants were divided into two groups (n = 30 each):
2.4. Surgical Technique
All operations were performed by experienced obstetricians using a standardized lower-segment transverse incision. Conventional methods ensured hemostasis in both groups; only the Surgicel group received additional application of ORC. The peritoneum and fascia were closed in layers.
2.5. Follow-Up and Assessment
Patients were followed for at least six months post-CS. Adhesion formation was evaluated either during repeat surgery or by imaging (MRI or high-resolution ultrasound with cine sequences). The modified Nair Adhesion Scoring System was used to classify adhesions by extent (percentage of uterine scar involved) and tenacity (adhesion strength). Two independent observers (surgeon and radiologist) blinded to patient allocation performed the assessments.
2.6. Statistical Analysis
Data were analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation and compared using Student’s t-test. Categorical data were compared using the Chi-square test. A p-value < 0.05 was considered statistically significant.
3. Results
3.1. Baseline Characteristics
There were no significant differences between groups regarding age, parity, or indication for CS (Table 1).
Table 1. Baseline characteristics of study participants.
Parameter |
Surgicel Group
(n = 30) |
Control Group
(n = 30) |
p-value |
Age (years) |
29.8 ± 4.2 |
30.2 ± 3.8 |
0.68 |
Parity (median) |
2 |
2 |
0.90 |
Elective CS (%) |
40 |
43 |
0.81 |
3.2. Adhesion Outcomes
Adhesions were detected in 20 patients (66.7%) in the Surgicel group and 10 (33.3%) in controls (p = 0.01).
The mean adhesion extent was 35% ± 10% versus 18% ± 8% (p = 0.02), and adhesion tenacity scores were 3.5 ± 0.8 versus 2.1 ± 0.6 (p = 0.01).
Omental adhesions were most frequently observed (14 vs. 7 patients).
These findings indicate that Surgicel use was significantly associated with both increased incidence and severity of adhesions.
4. Discussion
This study demonstrated that the intraoperative use of Surgicel on the uterine incision during cesarean section significantly increased the incidence, extent, and strength of postoperative adhesions. These findings align with earlier reports that oxidized regenerated cellulose materials can trigger fibroblast proliferation, collagen deposition, and a sustained inflammatory response [4] [5].
Possible mechanisms:
Surgicel may act as a foreign body, delaying peritoneal healing and causing localized fibrin deposition [3] [6]. As fibrin persists, it serves as a scaffold for fibroblast migration and vascular proliferation, leading to dense fibrous adhesions [2]. Additionally, incomplete degradation of ORC can perpetuate mild inflammation, amplifying adhesion risk [5].
Comparison with literature:
Gao et al. [3] found increased peritoneal fibrosis in rats treated with Surgicel compared to controls, supporting our findings. Similarly, Al-Tarakji et al. [5] observed a higher incidence of pelvic adhesions after gynecologic surgery involving Surgicel. In contrast, Becker et al. [7] reported no significant difference, possibly due to differences in exposure time and surgical environment. Holmdahl et al. [8] also suggested that rapid ORC absorption (within 7 - 14 days) may limit long-term fibrotic response, but this may vary with application site and tissue vascularity.
Clinical implications:
Adhesion formation after cesarean section poses challenges during repeat operations, including increased operative time, risk of bowel or bladder injury, and reduced fertility potential [1] [9]. Our findings underscore the need for cautious use of hemostatic agents on the uterine incision, especially in women with multiple prior CS or future pregnancy plans.
Study limitations:
The sample size was modest, and follow-up imaging may underestimate subclinical adhesions. Histopathologic confirmation was not performed. Larger randomized trials with longer follow-up and biochemical evaluation of fibrosis are recommended.
5. Conclusion
The use of Surgicel during cesarean section is associated with a significantly higher rate and severity of postoperative adhesions at the uterine scar, particularly involving the omentum. While Surgicel remains an effective hemostatic agent, its use on the uterine incision should be carefully considered. Alternative hemostatic methods or anti-adhesion barriers may be preferred in patients at high risk for repeat abdominal surgeries.
Acknowledgements
The authors thank the surgical and nursing staff of the Saudi National Hospital for their cooperation and support during data collection.