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.

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.

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.

The authors thank the surgical and nursing staff of the Saudi National Hospital for their cooperation and support during data collection.