Adhesions

Overview

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.

What are adhesions?

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.

What are abdominal adhesions?

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.

How do adhesions form?

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:

• 

  Adhesions secondary to surgery: One of the most common causes of adhesions is previous surgery. Adhesions form due to the body’s natural desire to maintain homeostasis (balance). Surgery is not something the body is used to, so it is only natural that adhesions may form during procedures. Keep in mind that surgery should only be performed as a last resort, and if other treatment options are not beneficial to the patient. The point of conducting surgery is to benefit the patient and relieve their symptoms. However, this does not mean that complications cannot arise and risks are not involved, one of which is adhesion formation. For these reasons, it is important to discuss with your doctor if surgery is the right choice for you, and if so, speak with your surgeon about the ways they ensure minimal risk and a minimally invasive surgical approach.
• Adhesions secondary to infection: Infectious disease can often lead to adhesion formation. For example, the infection that causes pelvic inflammatory disease (PID) can often lead to adhesion formation within the pelvic cavity, particularly within the fallopian tubes. These adhesions can be a cause of concern, as they can increase a woman’s risk of infertility and ectopic pregnancy.
• Adhesions secondary to innate pathology (i.e. endometriosis): When we say adhesions caused by pathology, we mean adhesions forming due to a much larger disease and concern. Endometriosis is just one example of such. Endometriosis adhesions, composed of ectopic endometrial tissue, inflammatory enzyme and old, pooled menstrual blood, can form throughout the pelvic cavity. These adhesions can be a cause of concern as their formation can increase a patient’s chances of not only experiencing the symptoms (painful periods, heavy menstrual period, etc.) of the underlying disease, but can also put the patient at greater risk to adopt congruent disorders such as infertility and bowel dysfunction or even obstruction.

What forms of surgery commonly lead to pelvic adhesion formation?

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.

What are the symptoms that pelvic adhesions cause?

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:

• Above the liver, involving the diaphragm (the membrane below the lungs): Pain with deep breathing.
• Bowel: Painful bowel movements, cramps, constipation, diarrhea, gas, bloatedness, nausea, vomiting, decreased appetite, weight loss, difficulty passing stool (manual dis-impaction etc.)
• Vagina & Uterus: Pain with intercourse or menstruation.
• Any location: None. Remember, not all adhesions cause pain and not all pain is caused by adhesions.

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

Why are endometriosis adhesions unique?

Endometriosis adhesions are unique and different than 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.

How do endometriosis adhesions progress?

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 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.

What are the steps of progression?

1. Peritoneum Invasion: During early endometriosis, the primary organ affected is the peritoneum (the lining of the abdomen). However, the exact cause leading to the progression of stage one endometriosis and further development is unknown. While several theories have been put forth, ranging from Sampson’s theory of retrograde menstruation to the stem cell theory of endometriosis, it is likely that there may not be one singular cause, but rather a multitude of mechanisms working alongside one another. Either way, small patches and lesions of endometriosis tissue within the peritoneum is a common anomaly in cases of early endometriosis development.
2. Endometrioma: In more severe cases of endometriosis, it is not uncommon to find endometriosis tissue on the ovaries. This collection of endometriosis can cause the formation of an ovarian cyst called an endometrioma, which is also composed of pooled menstrual blood and inflammatory enzymes. This “chocolate cyst,” termed after the brown serous fluid it consists of, is then susceptible to leakage during menstruation and subsequent further spreading of endometriosis within the pelvic cavity. This leakage material can then go on and form adhesions throughout the pelvic cavity.
3. Deep infiltrating endometriosis: When the leakage of this material spreads throughout the pelvic cavity, endometriosis adhesions grow and spread. These adhesions serve as a “glue” that holds inflamed pelvic organs in place and can ultimately result in extreme cases like frozen pelvis. This can cause symptoms such as chronic pelvic pain, killer cramps, and pain with sexual intercourse.

Where do endometriosis adhesions commonly form?

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:

• Uterus muscle layer or serosa layer (adenomyosis)
• Fallopian tubes
• Ovaries (endometrioma)
• Bladder
• Ureter
• Cul-de-sac (both posterior and anterior)

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:

• Peritoneum
• Rectum
• Colon (large intestine)
• Appendix
• Ileum (final section of small intestine)

In rare instances, endometriosis implants and adhesions can incorporate a variety of other locations, which include:

• Cervix (excluding endometrial layer)
• Vagina
• Nerves
• Lungs
• Brain

How can endometriosis lead to retroperitoneal fibrosis?

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 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.

Diagnosing & Treating

How are adhesions diagnosed?

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 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.

What are some ways pelvic adhesion pain can be relieved?

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.

How can diet play a role in pelvic adhesion symptom relief?

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.

How are adhesions surgically treated?

The two most common forms of surgically treating pelvic and abdominal adhesions are laparoscopy and laparotomy, which differ primarily in terms of invasiveness.

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  Laparoscopy: In this minimally invasive surgical technique, a doctor makes several small incisions into the abdomen, which is then inflated with gas. A small camera, termed a laparoscope, is then inserted through one of these small incisions to visualize the abdomen and pelvic cavity and confirm that adhesions are present. Other tools are then inserted through the two or three other incisions so the adhesions can be cut and released, a process known as adhesiolysis.
• Laparotomy: This is an open surgical technique where a large incision is made from the navel (belly button) down the abdomen, giving a surgeon full access and visualization of the abdominal and pelvic organs. This is a much more invasive technique and thus presents more risk of difficult recovery. For this reason, in most cases of adhesions, laparoscopy is the preferred form of surgery, but can only be performed in the hands of an experienced and skilled surgeon. It is important to remember that surgery in itself can cause adhesions and there are few proven methods to prevent this.

Our Approach

What is our approach to surgically treating pelvic adhesions?

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.

REFERENCES

1. Endometriosis Foundation of America https://www.endofound.org/endometriosis.
2. Vafa Shayani, Claudine Siegert, and Philip Favia. “The Role of Laparoscopic Adhesiolysis in the Treatment of Patients with Chronic Abdominal Pain or Recurrent Bowel Obstruction.” Journal of the Society of Laproendoscopic Surgeons (JSLS). 2002 Apr-Jun; 6(2): 111–114. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043421/
3. Brüggmann et al. “Intra-abdominal Adhesions Definition, Origin, Significance in Surgical Practice, and Treatment Options.” Dtsch Arztebl Int. 2010 Nov; 107(44): 769–775. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2992017/
4. Judith S. Moore., Endometriosis in patients with irritable bowel syndrome: Specific symptomatic and demographic profile, and response to the low FODMAP diet. The Australian and New Zealand Journal of Obstetrics and Gynecology, Volume 57, Issue 2 April 2017: p. 201-205. //onlinelibrary.wiley.com/doi/10.1111/ajo.12594/abstract
5. Reich Harry., Laparoscopic Surgery for Adhesiolysis. Attending Physician, Wyoming Valley Health Care System, Wilkes-Barre, PA Corresponding Author: Harry Reich, M.D. https://www.adlap.com/PDF/adhesion.pdf
6. Seckin, T., The Doctor Will See You Now: Recognizing and Treating Endometriosis. 2016.