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Adhesion

An adhesion is a band of scar tissue that initially develops as part of the body’s natural repair mechanism in response to any tissue disturbance, such as from:
– surgery
– infections
– trauma
– radiation
– or pathologies like endometriosis.

Adhesiolysis

Adhesiolysis is the term for the surgery that is performed to remove or divide adhesions so that normal anatomy and organ function can be restored and painful symptoms can be relieved.

In some rare cases, adhesions form without visible or known tissue trauma. While some adhesion formation is part of the normal healing process, in some cases excessive scar tissue can develop, disproportionate to the original injury. As is shown in the pictures below, adhesions can bind your organs or tissue together in a way that begins to cause pain, organ dysfunction, or other symptoms. In some rare cases, adhesions can even cause life-threatening injuries, such as bowel obstruction.

Adhesions may appear as thin, avascular sheets of tissue similar to plastic wrap or as thick, vascular fibrous bands of adhesions, which are considered the more severe and more difficult to remove.

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Band of thin, avascular adhesions inside the pelvis

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Band of thick, vascular adhesions on the ovary

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Another image of thick, vascular adhesions of the ovary.

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Another image of thick, vascular adhesions of the pelvis

ABDOMINAL ADHESIONS:

Abdominal adhesions may involve any organ within the abdomen, such as the uterus (including inside of the uterus, as occurs in Asherman’s Syndrome), ovaries, fallopian tubes, bowel, bladder, appendix, ureters, liver, kidneys, and spleen.

Although one of the leading causes of adhesions is surgery, infections can also cause them to develop. For example, pelvic inflammatory disease (PID) results from an infection that frequently leads to adhesions within the Fallopian tubes. A woman’s eggs pass through her fallopian tubes into her uterus for reproduction. Therefore, fallopian tube adhesions can lead to infertility and increased incidence of ectopic pregnancy in which a fetus develops outside the uterus.

Abdominal adhesions are a common complication of major open surgery, occurring in up to 93% of people who undergo traditional open abdominal surgery. However, surgeries performed in a minimally invasive way have been shown to significantly reduce the number of adhesions, particularly the severe form. For example, in one study, almost all of the patients who had open abdominal surgery later developed a dense network of thick, vascular adhesions, which, again, are the more serious type. In contrast, only 48% of patients in the minimally invasive group developed adhesions. And in those cases, they were the thin, avascular form, considered less severe because they cause fewer symptoms.
Abdominal adhesions also occur in 10.4% of people who have never had surgery. Depending on the severity of the adhesion and the location, the indication of pain can differ. However, adhesions cause 60%-70% of small bowel obstructions in adults and are believed to contribute to the development of chronic pelvic pain.

Adhesions typically begin to form within the first few days after surgery, but they may not produce symptoms for months or even years. As scar tissue begins to restrict motion of the small intestines, passing food through the digestive system becomes progressively more difficult; the bowel may become blocked. In extreme cases, adhesions may form fibrous bands around a segment of an intestine. This constricts blood flow and leads to tissue death (necrosis).

ADHESIONS SYMPTOMS:

Typically, patients with adhesions actually experience few or no symptoms at all.
However, in more severe cases, adhesions can cause pain by pulling nerves, either within an organ tied down by an adhesion or within the adhesion itself. Other signs and symptoms include:

– Adhesions above the liver may cause pain with deep breathing
Intestinal adhesions may cause pain due to obstruction during exercise or when stretching
– Adhesions involving the vagina or uterus may cause pain during intercourse
– General pelvic pain
– Partial or complete loss of organ function or tissue death in more severe cases
– Ovulatory disruptions when the ovaries are involved
– Diminished fertility
– bowel obstruction

Why are adhesions particularly prevalent in women with endometriosis?
Patients with endometriosis often have more adhesions than average. In fact, the term frozen pelvis was used to describe the effects of severe adhesions, which can cause essentially all of the organs and structures in the pelvis to freeze together, what one early 20th century endometriosis specialist described as appearing as if crazy glue had been poured into the abdomen.
Adhesions form in endometriosis patients for a variety of reasons. For example, it is hypothesized that the body recognizes theendometriotic lesions as pathological and, as a result, signals the immune system to send in its enzymatic troops to fight the abnormal growths (aka, the inflammatory process) and repair the tissue damage (aka, adhesion-formation as one of manyreparative processes). Another common area where adhesions often form in women with endometriosis is on the ovaries. This occurs because the ovarian cysts common to women with endometriosis (endometriomas, etc) often leak out their contents, again triggering the body’s inflammatory and subsequent reparative processes. If left untreated, the ovaries could become totally adherent to other organs or become completely encased in the scar tissue itself.

In other cases, during previous surgeries the ovarian cysts may have been treated incompletely or incorrectly. In such cases, the body’s inflammatory and reparative responses will persist, bringing with it chronic pain and still more adhesion-formation. Another common reason that adhesions develop in women with endometriosis is related to the number of surgeries that they have had to endure over their lifetimes. Sadly, in the days before minimally invasive surgery, it was common to see patients who had had 7 or more laparotomies, which in turn led to a high incidence of surgery-induced (iatrogenic) adhesion disorders.

Again, although very rare, in some cases adhesions can cause life-threatening conditions, such as severe bowel obstruction. Those who have had multiple laparotomies are at higher risk for developing these severe cases. However, it’s also important to emphasize that not all pain is caused by adhesions and not all adhesions cause pain.

ADHESIONS DIAGNOSIS:

Depending on the clinical symptoms, x-rays may reveal the small obstructions caused by adhesions. If pain is the only symptom and there is no evidence of obstruction, many other tests may be done to confirm the diagnosis. For example, visually examining inside of the body with various scopes (endoscope, colonoscope, hysteroscope, sigmoidoscope, proctoscope) can identify strictures which may have formed as a result of adhesions. MRI evaluation may be useful in some cases. In cases in which the diagnosis is questionable, videolaparoscopic surgical exploration and visualization may be the best option for determining a definitive diagnosis.

Prevention
At the present time, there is no definitive cure for the prevention of adhesions. However, studies have shown that some adhesion barrier products, like Sepra Film and Intercede, can be helpful in certain situations.

ADHESIONS TREATMENT (videolaparoscopically):

Adhesions within the abdomen can be effectively treated videolaparoscopically. Lysis of adhesions (adhesiolysis or enterolysis if it’s inside or near to the intestines (aka, bowel, rectum, colon, etc) can be performed as a part of other procedures (such as removal of ovarian cysts or fibroids), or as a procedure by itself. A common misconception is that adhesions are a contraindication to performing videolaparoscopy. However, this is definitely not true. In fact, videolaparoscopy offers several advantages over laparotomy in the treatment of adhesions. The laparoscope allows excellent visualization and magnification of the adhesions and the affected abdominal/pelvic organs. In addition, the CO2 gas which is used to inflate the abdomen provides a natural separation of the abdominal structures, allowing the adhesions to be clearly defined and effectively treated. The microsurgical principles which are employed with a laparoscopic approach are also much more effective in preventing the development of adhesions from the surgery itself.

Recovery from adhesiolysis is fast, with patients usually discharged from the hospital within 24 hours. A return to normal activities can be expected within 1-2 weeks.

Determining whether a patient is a candidate for adhesiolysis must be assessed on a case by case base.

FURTHER READING
If you would like to read more about adhesions, please see the below-listed sources, including several health blogs by women with endometriosis, YouTube videos showing the removal of adhesions (adhesiolysis), as well as peer-reviewed medical journal articles from our reference library:

  1. Helpful website dedicated to adhesion disorders: http://www.adhesionpain.net/
  2. Dr. Nezhat’s textbook on Google Books. There isn’t one chapter dedicated to adhesions. However, if you search the term adhesions you’ll find dozens of pages which provide more detail about how Dr. Nezhat surgically manages this condition: http://books.google.com/books?id=Z0gYy2hdn3QC&q=adhesions#v=snippet&q=adhesions&f=false
  3. Textbook chapter written by the Drs. Nezhat and their colleagues. Although it was written for surgeons, nevertheless we think you’ll find it provides a fairly clear and concise overview: http://laparoscopy.blogs.com/prevention_management/chapter_21_adhesiolysis/

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Adhesions / Adhesiolysis.