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Preoperative nomogram to predict risk of bowel injury during adhesiolysis. BJS 2014; 101: 720-727.

Published: 10th April 2014

Authors: R. P. G. ten Broek, C. Strik, H. van Goor


Inadvertent bowel injury during adhesiolysis is a major cause of increased morbidity and mortality following abdominal surgery. Identification of risk factors predicting this complication would guide preoperative counselling and surgical decision‐making. The aim of this study was to identify predictive preoperative factors for inadvertent bowel injury occurring during adhesiolysis.


All patients undergoing elective abdominal surgery between June 2008 and June 2010 were evaluated prospectively as part of the LAPAD study. Data on adhesiolysis and inadvertent organ injury were gathered by direct observation during operation. Univariable logistic regression was used to investigate factors that increased the risk of inadvertent bowel injury. Independent predictors of bowel injury were identified using multivariable logistic regression and used to create a clinical nomogram.


Of 715 patients eligible for analysis, 48 (6·7 per cent) had inadvertent bowel injuries. In 42 patients the defect was detected during operation and in nine at a later time (3 patients had both). Bowel resection was required for almost two‐thirds of the enterotomies. The number of previous laparotomies, anatomical site of the operation, presence of bowel fistula and laparotomy via a pre‐existing median scar were independent predictors of bowel injury. A clinical scoring system was constructed using a nomogram incorporating these risk factors; this had a predictive discrimination, measured as the area under the receiver operating characteristic curve, of 0·85.


A nomogram based on four independent factors predicted the risk of inadvertent bowel injury. Registration number: NCT01236625 (http://www.clinicaltrials.gov).

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