by Tamer Seckin, MD | Posted on September 20, 2019
Endometriosis is the most common cause of adhesions located in the pelvic and abdominal cavity. Years ago, the most common cause of adhesions was thought to be pelvic inflammatory disease (PID). Endometriosis adhesions cause scarring and fibrous bands to form, which contain endometriosis glands, stroma, and inflammation, as opposed to more typical adhesions caused by repeated surgery, which contain only fibrous bands. The most common endometriosis adhesions form and cause scarring within the ovaries, fallopian tubes, uterus, small intestine, and pelvic sidewall, between the bowel, rectum and recto-vaginal septum. These “sticky” adhesions can cause the space between two distinct organs to fill with scar tissue and inflammatory enzymes. This ultimately can cause pain in the pelvic and abdominal cavity. For these reasons, it is important to clearly define adhesions, state their role in endometriosis development, and discuss treatment options for patients who feel discomfort from endometriosis adhesions in their day-to day life.
Pelvic adhesions are fibrous bands of scar tissue. What makes this tissue concerning is its ability to fuse together two different tissues. This generally occurs in the form of thick fibrous bands of tissue, but it can also present as thin sheets.
The organs inside the abdomen and pelvic cavity have a very special characteristic in that they are slippery, shiny, and are constantly moving. Adhesions are the bands that form between organs and limit their movement and function, thus causing pain. In more medical terms, adhesions are defined as the newly-formed scarring between peritoneum surfaces. These adhesions can spread onto the intestines and are thus the leading cause of bowel obstruction, causing such symptoms as small stool production, constipation, and nausea.
Most adhesions form in response to a tissue disturbance that triggers the body’s repairing mechanism. There are a variety of ways this mechanism can be triggered, including:
After a c-section: Following a c-section, it is common for adhesions to form in the bladder with a band-like tightness that spans to the anterior wall of the uterus. This can cause difficulty or pain with urination.
After a myomectomy: A myomectomy is the removal of fibroids. Even upon laparoscopic procedures, adhesions can form along the anterior and posterior uterine wall. In fact, it has been noted that bleeding can often arise upon posterior myomectomy procedures. For this reason, it is crucial that you find a surgeon who will actively work to minimize bleeding through meticulous skill and experience in order to ensure a reduced risk for further adhesion formation and loss of blood.
After a hysterectomy: Even when the uterus is removed, adhesions can form on the surrounding reproductive and pelvic organs, ranging from the ovaries to the bowels and bladder.
Pelvic adhesions can vary in symptoms, depending on their severity and where they are located in the body. However, physicians usually attribute these symptoms to the conditions and diseases that adhesions cause, as opposed to the adhesions themselves, leading to misdiagnosis or inefficient treatment. The most common universal symptom that adhesions can cause is pain due to pulling on nerves. This occurs as the adhesions will glue together organs due to their “sticky” quality, causing overlapping and pressure on specific nerves and tissue within the area. Other symptoms vary depending on the location of adhesion development, and include:
If you are experiencing any of these symptoms, and feel that pelvic adhesions are a probable cause of your pain, then you should alert your gynecologist immediately.
Endometriosis adhesions are unique and different from any other form of adhesions. They are often described as a sort of super glue. This is because they possess a certain “sticky” component that makes them fuse other tissues together and connect organs, eliminating what is referred to as the dissection line during surgery. Normally, this space is clearly defined and separates adjacent organs, but in the case of endometriosis, it is remarkably difficult to distinguish the line of tissue that is supposed to separate said organs. The loss of normal surgical planes can change the contour of an organ, such as the rectum, uterus, and ovary, making surgery very difficult.
Endometriosis adhesions are “alive,” meaning they contain glands and stroma with endometriosis tissue within the adhesions that are reactive to estrogen. These adhesions can be understood when one imagines the leakage of endometriosis material from a chocolate cyst (endometrioma). The melted chocolate material, which is a combination of pooled menstrual blood, inflammatory enzymes, and endometriosis tissues produced from an endometrioma, fuses organs together by forming a layer of “sticky” glue-like tissue. Thus the endometriosis tissue contained within this material can be thought of as responsible for progressing into more advanced and severe adhesions that fuse organs together in extreme cases. When organs are fused together they cannot function well. This leads to issues such as rectal constriction, causing constipation, or retroperitoneal infiltration, leading to retroperitoneal fibrosis. This can also cause severe sharp pain with intercourse or an inability to tolerate it with a deep pulling sensation. Other inner anatomical abnormalities that can arise from adhesions include the blocking of the ureter and bowels and deep cul-de-sac scarring and obliteration. In this sense, endometriosis adhesions are unique and atypical in comparison with the adhesions that form due to surgery.
Most commonly, endometriosis adhesions adhere to the pelvic cavity due to their uterine origin. Below are a few common organ sites within the pelvic cavity that endometriosis adhesions adhere to:
Organs within the abdominal cavity are also commonly affected, particularly in cases of bowel endometriosis, which is seen in nearly one in every five endometriosis patients. Common sites within the abdominal cavity that endometriosis adhesions adhere to include:
In rare instances, endometriosis implants and adhesions can incorporate a variety of other locations, which include:
Retroperitoneal fibrosis is when fibrous adhesions form in the space behind the peritoneum (lining of the abdomen). This can often be caused by endometriosis adhesions infiltrating the peritoneum and spreading through the wall. When this occurs, the adhesions can continue to spread and are often associated with the involvement of the ureter and deep nerves. This will cause such symptoms as neuropathy (pain due to nerve damage), particularly to the legs and below the lower abdomen. In these cases, it is important that these adhesions are meticulously removed through “cold” excision surgery, using minimal to no electrical energy. In this way, the pelvic and abdominal cavity is repaired/restored and reconstructed back to normalcy.
Although adhesions are not a formal medical diagnosis, we strongly recommend that you see a doctor if you experience these symptoms. The underlying pathology causing adhesions cannot be identified by any simple form of a diagnostic exam. In order to identify the underlying pathology behind adhesions, a biopsy sample must be taken during laparoscopic surgery. This specimen must then be sent to a pathology lab, where a pathologist will observe the sample under a microscope and provide a report with an official diagnosis.
While adhesions must be diagnosed and treated medically, treatment can vary depending on the severity and location of the adhesion formation, as well as the bigger issue that the adhesion is causing. However, because many adhesions do not cause any symptoms at all, surgery does not become necessary unless an emergency becomes evident. In fact, adhesions often improve without surgery, and even in instances of mild pain, a physician will more commonly treat the symptoms then go to such extensive measures as surgery.
While a diet certainly cannot rid a patient of their pelvic and abdominal adhesions, it can help play a role in symptom relief. Because abdominal adhesions can implant on the bowels, they often mask themselves as other disorders, causing symptoms similar to those of irritable bowel syndrome (IBS). These can include nausea, constipation, small bowel production, and bowel obstruction. For these reasons, it can be helpful to adopt lifestyle and diet changes that can help relieve such symptoms. For more information, visit our bowel surgery page, where we detail a low FODMAP diet.
The two most common forms of surgically treating pelvic and abdominal adhesions are laparoscopy and laparotomy, which differ primarily in terms of invasiveness.
At SEC, we are committed to performing laparoscopic surgery. We believe that a patient’s best chance of a healthy recovery and symptom relief is through minimally invasive surgery. For these reasons, we perform excision surgery to remove all suspected adhesions as an initial step in surgery. Additionally, we are able to better view and thus remove endometriosis adhesions through our patented ABC technique. Our method differs from traditional adhesiolysis in that we firmly believe that both endometriosis adhesions and their surrounding scar tissue must be meticulously surgically removed through excision. This ensures that adhesions are fully removed individually, including the underlying tissue beneath the surface. After decades of training and experience and with the utilization of a team surgical approach, we are able to provide a highly thorough and productive surgery, which includes repairing, reconstructing, and restoring the organs that were operated on.
If you or your doctor feel that you could be at risk of having pelvic adhesions and have had constantly recurring pain and symptoms, please feel free to call us to discuss your case. Pelvic adhesions due to endometriosis can be a very grueling condition to endure, and even more so to treat. For these reasons, we have worked tirelessly to improve upon our techniques in order to ensure that our patients receive the conservative and definitive surgery that they both need and deserve.
Medically reviewed by Tamer Seckin, MD on September 20, 2019
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