Efficacy of commercially available adhesion barriers in abdominal surgery: a systematic review of randomised controlled trials

Introduction: Postoperative peritoneal adhesions remain an almost inevitable consequence of abdominopelvic surgery, causing small bowel obstruction, infertility, chronic pain, and significant healthcare costs. Numerous adhesion prevention agents have been introduced, yet their comparative efficacy and safety remain uncertain.
Methodology: This systematic review was conducted in accordance with PRISMA guidelines. Electronic databases including PubMed, Web of Science, and Google Scholar were searched up to August 2025. Randomized controlled trials (RCTs) and controlled clinical studies evaluating adhesion prevention agents in abdominal or pelvic surgery were included. Data extraction focused on study characteristics, interventions, adhesion-related outcomes, complications, and follow-up.
Results: Ten eligible trials were analyzed. Hyaluronic acid/carboxymethylcellulose (HA/CMC) gels and membranes demonstrated consistent reductions in adhesion severity and extent, with Guardix-sol, Guardix-SG, and TCD-11091 showing the most favorable outcomes. Starch-based polysaccharides (4DryField PH) achieved up to an 85% reduction in adhesion scores at second-look laparoscopy and were associated with improved fertility and pain outcomes, though safety concerns were reported in pediatric and retrospective cohorts. Collagen membranes (COVA+), thermosensitive gels (Mediclore, Actamax), and fibrin sealants (Adhexil) showed promising early results but require larger confirmatory studies. Conversely, icodextrin (Adept) and spray powders such as Sepraspray yielded inconsistent benefit. Safety was generally acceptable, though powders occasionally correlated with higher complication rates.
Conclusion: Evidence supports the selective use of HA/CMC-based gels and starch-derived barriers for adhesion prevention in high-risk surgical contexts. However, heterogeneity across trials, short follow-up, and lack of standardized adhesion scoring limit definitive recommendations. Adhesion barriers should be considered as adjuncts to meticulous surgical technique rather than substitutes. Future directions include bioactive, multifunctional platforms (Janus hydrogels, plasma-activated solutions, metabolic modulators, phytochemicals) and robust RCTs incorporating fertility, obstruction, pain, and cost-effectiveness as patient-centered endpoints.
PROSPERO ID: CRD420251119090