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. Surgery involving the ovaries, endometriosis, the Fallopian tubes, fibroids and adhesions themselves can result in the formation of adhesions. The more extensive the surgery, the more likely adhesions will form or reform. Stitches used 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.
The following can be caused by:
- 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, abscess, gastroenteritis.
What are the problems caused by adhesions?
- Pain – It appears that some adhesions may 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 a narrowing of the bowel known as a stricture. This may result in the blockage of the bowel leading to a condition known as bowel obstruction. 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 by scar tissue and can result in pain during deep penetration.
- Infertility – Scar tissue can result in the ovaries being displaced from their normal position, or in the blockage of the Fallopian tubes interfering with the process of egg production (ovulation) and egg transport through the Fallopian tubes. A blocked Fallopian tube can result in a condition called “hydrosalpinx” whereby fluid accumulates within a blocked tube. Such a condition can interfere with the success of pregnancy even during assisted conception ( test tube baby). Adhesions can result in the pelvic organs being attached to each other abnormally eg. bowel to uterus, uterus to bladder.
What do adhesions look like?
What can be done for adhesions?
Laparoscopic (keyhole) procedures
This the only way adhesions can be removed, although adhesion reformation is still a significant problem.. Research is currently ongoing in this controversial area with some studies suggesting the removal of adhesions is unhelpful (Swank et al) whilst others suggest it to be helpful (Cheong 2014). 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) and using good surgical technique with adequate treatment of diseased tissue such as endometriosis. However extensive surgery for the removal of endometriosis requires careful consideration given that such surgery can result in significant and severe complications. It is important to discuss the pros and cons of surgery with your surgeon before embarking on adhesion removing surgery and at the same time explore adhesion reducing strategies that they may be using.
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.
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); and
- solutions (broad coverage within the abdominal cavity).
Issues to be discussed with your surgeon before proceeding to surgery:
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. You may want to ask whether any adhesion prevention product will be used during your surgery and if so which product.
- Ask about the risks of surgery before you give consent. You may also want to check what it says on the consent form.
- Exercise increases endorphins and is a good coping mechanism to help with chronic pain. However, if exercise worsens your pain, it is wise to discuss this with your doctor /physiotherapist.
The future of adhesion prevention
There is currently no adhesion reduction product that can completely prevent the occurrence of adhesions. 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. Ideally, patient registries where long term patient data can be captured should be established.
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.