This information aims to give patients and those interested in adhesions an overview of what adhesions are, how they form, what causes them, the problems they can cause, what can be done about them and current research in the field.
What are adhesions?
Adhesions are deposits of fibrous strands/scar tissue which can connect organs together. Organs in the peritoneal cavity (pelvic/abdominal space) normally slide freely against each other and adhesions can hinder this movement leading to such complications as pain, infertility and bowel obstruction. Adhesions are usually the result of injury to the peritoneum (lining of the abdomen and pelvis) and are part of the normal wound healing process. They do not always lead to problems but when they do cause difficulties, these can be widespread and severe.
How do adhesions form ?
The internal lining of the abdominal cavity and pelvis (the peritoneum) can become injured during surgery or by other processes such as infection. An inflammatory process occurs at the site of injury with the release of fluid and inflammatory cells. This mixture solidifies and a process then follows similar to the formation of a blood clot and then scab that you would see on any skin wound. The process involves macrophages (special cells of the immune system) which release various inflammatory substances that attract new peritoneal cells to the site of the injury to form a repair. During this process another set of cells called fibroblasts are involved in the formation of a fibrin gel matrix. This seems to have an important role in adhesion formation with an increase in production of strands of proteins which tighten to form a mature adhesion. It is unclear however why the severity and extent of adhesions some people develop differs from others.(Roman H, 2010)
What are the causes of adhesions?
Surgery : there is an increased risk of adhesions after abdominal and pelvic surgery. Some types of surgery carry a higher risk of resulting in the development of adhesions. This includes ovarian, endometriosis, tubal, myomectomy (removal of fibroids) and adhesiolysis (removal of adhesions). Stitches during surgery can result in adhesions. Adhesions can begin to form immediately after surgery and certainly are formed within the first 5 days following surgery.
Inflammation. The following can cause inflammation:
- Inflammation - pelvic inflammatory disease, inflammatory bowel diseases (Crohn's disease, ulcerative colitis) appendicitis, especially if the appendix ruptures
- Infection: any type of infection can lead to adhesions if it is not treated quickly and effectively eg pelvic inflammatory disease, abcess, gastroenteritis
What are the problems caused by adhesions?
- Pain - It appears that some adhesions cause pain by restricting mobility of mobile organs in the abdomen/pelvic cavity eg. Bowel and ovaries. Furthermore, nerve endings may become entrapped within developing adhesions. The pain can be local or deep in the pelvis.
- Bowel obstruction-dense adhesions can cause kinking and stricture of the bowel. This is blockage of the bowel. Surgery to perform a hysterectomy is a common cause of blockages of the bowel after surgery. Research has demonstrated that it is cost-effective to use adhesion prevention barriers to prevent these complications of surgery. ( Bristow RE, 2007)
- Bladder problems - adhesions can reduce the capacity and proper emptying of the bladder causing pain and frequency - which can be mistaken for cystitis.
Dyspareunia- pain during sexual intercourse. This can be caused when the ovaries become stuck down and by local trauma during deep penetration.
- Infertility - can be produced by adhesions in different ways depending on their site. Adhesions around the ovary can interfere with ovulation. If they are around the ends of the fallopian tubes there can be problems with picking up the egg following release from the ovary. If adhesions are around the Fallopian tubes, transport of the egg through the tube may be restricted. If the ends of the Fallopian tubes are blocked, it can cause a condition called hydrosalpinx. This is when the Fallopian tube is swollen with fluid. This condition if not treated, can significantly decrease the chances of getting pregnant. Adhesions around the uterus (womb) can cause it to be bound down. The uterus can become attached to the bowel. This may be described as a fixed or immobile uterus. This is when the uterus is tethered to the bowel.The uterus can also become attached to the bladder.
What do adhesions look like ?
What can be done for adhesions?
Laparoscopic ( keyhole) procedures appear to reduce new adhesion formation. Research is currently ongoing in this area. Peritoneal injury may be minimized by using filtered, heated and humidified gas instead of the frequently used dry gas (there are currently very few centres or surgeons using warm/humidified gas).
Good surgical technique:
- Preserving good blood flow
- The least possible tissue handling of tissue
- Use of microsurgical instruments
- Powder-free and even starch-free gloves should be used because of the association with adhesions
- Meticulous care with stopping bleeding
- Use of fine material for stitches
- Control of infection
All diseased tissue should be excised ( cut out ) - because endometriosis can hide beneath adhesions, it is vital to completely excise the scar tissue to be certain no endometriosis is left behind. This however can be difficult, as some disease cannot be seen by the naked eye. Extensive surgery with increased complications may be needed in severe cases of endometriosis and the pros and cons of proceeding with this kind of surgery should be discussed thoroughly with your doctor.
Use of adhesion prevention products - some adhesion prevention products have been removed from the market in recent years. There are two main categories of products several of which are currently under study:
- physical barriers, films and gels (these are site specific ie for localized use)
- solutions (broad coverage within the abdominal cavity)
ANY TECHNIQUE IS ONLY AS GOOD AS THE SURGEON USING IT !!
Adhesions are often not discussed with patients. ( Kraemer B, Birch JC et al 2010) In our opinion, patients who are going to have an abdominal or pelvic surgery should ask the surgeon about the following :
As a patient:
- Ask your surgeon what precautions and strategies they take to prevent adhesions
- Ask about the risks of surgery before you give consent. You may also want to check what it says on the consent form.
- Exercise may help to make the adhesions flexible and help to reduce pain. This should be gentle ongoing exercise. A physiotherapist may be able to help with this. If exercise and activity cause a worsening of pain in the long term, you should seek advice from a doctor.
The future of adhesion prevention
Further advances are likely to occur over the next few years.
It is likely that some adhesion products will be more suited to some sites than others. In our opinion patient registries should be established. These should provide more useful long term data on outcomes for patients.
Chronic pelvic pain affects nearly 15% of women aged between 18 and 50. The treatment of chronic pelvic pain is emerging as a multidisciplinary speciality. This means a team of pain specialists, anaesthesiologists, neurologists, urologists, general surgeons, physical therapists, gynaecologists and nurses working in a coordinated manner to achieve maximum benefit for the patient.
Do your homework before you are referred - you can request to be referred to a specific surgeon. Be sure to ask your surgeon what precautions they take to prevent adhesion formation. If your surgeon is not open to discussing this, you can seek a surgeon who does or request a second opinion.
Royal College of Obstetricians and Gynaecologists Consensus in Adhesion Reduction Management (2004)
European Society of Gynaecological Endoscopy (ESGE) Consensus for Reducing Adhesions. Article
Issue date: February 2012
Review date February 2015