LaparoscopicAdhesiolysis.org

Our strategy: Lift-Laparoscopc adhesiolysis

informer — Tue, 10 May 2011 07:39:41 +0000

ADHESIONS : OUR STRATEGY

Since March 2001 we have been using this novel spray substance (spray gel) to prevent adhesions following gynaecological surgical procedures.

In general, adhesions are formed after all surgical measures involving laparotomy.

But even during laparoscopy, which is a form of minimally invasive surgery, wound surfaces can be formed during certain procedures, such as for example endometriosis or myoma operations.

These surfaces can adhere to each other, thus forming adhesions.

These adhesions can later cause problems such as pain, adhesion of the uterine tubes (infertility) or of other organs (intestines / ovaries / uterus).

They thus have the potential to cause chronic problems and pain requiring tedious treatment measures, and possibly even adhesiolysis, a follow-up surgical procedure to remove these adhesions.

The new gel substance (SprayShield™) is sprayed onto the wound surfaces, where it remains in place for some days after surgery.

Since adhesions are formed within 7 days of surgery, the barrier system thus prevents formation of adhesions.

After this period, SprayShield™ is then broken down and simply absorbed by the peritoneum and excreted from the body via the kidneys.

The carbon dioxide customarily used to insufflate the abdomen during laparoscopy converts the entire peritoneum into an acidic environment.

This thus results in oxygen being withdrawn from the tissues and can cause cells to die, with formation of global wound surfaces in the peritoneum and abdominal organs

By using gasless laparoscopy, we avoid insufflation with carbon dioxide, which has been shown by recent studies — for the aforementioned reasons — to be a co-factor adhesion formation.

But since wound surfaces are always formed during surgery because of tissue layers being separated, the formation of adhesions can additionally be prevented on such surfaces by spraying them with SprayShield™.

Hence in the gasless laparoscopy technique and SprayShield™ we have an ideal combination that helps to prevent the occurrence and formation of adhesions.

Dr. Kruschinski has now performed adhesiolysis on around 700 cases using the technique of gasless lift-laparoscopic adhesiolysis with SprayGel™ / SprayShield™ application

Adhesions are known to form as soon as three hours after the completion of a surgical procedure – and will continue to form for up to about seven days.
If any adhesions have formed during this critical time period, they can easily be “swept down” by the surgeon during a second look laparoscopy – and more SprayGel can be applied, if needed.

Dr. Daniel Kruschinski is one of the very few surgeons in the world, who performs a second look laparoscopy (SLL) about seven days after the initial surgical procedure.

In Dr. Kruschinski’s experience the risk of adhesions resulting in the need for a subsequent surgery is greatly reduced. He has mastered the required advanced microsurgical laparoscopic techniques and has logged thousands of hours in performing very difficult, time-consuming, risky surgical procedures.

Repeat surgery for adhesions in these cases is usually less extensive and does not usually involve the same amount of dissection that led to the formation of adhesions in the first place
Here are some of Dr Kruschinski’s results in general

About 89,9 % are adhesion free at the 2nd laparoscopy at 7 days postoperative.
In those patients who have small adhesion attachments to the surgery sites at the second look laparoscopy 7 days post-operatively, these attachments are removed very easily by simply touching them with an instrument.
Only 10% developed pain after surgery and had a third look laparoscopy in which adhesions were seen to be the cause of pain, the scores were reduced when compared to the initial surgery, especially in grade and severity. In other cases there were other reasons fo pain like adnexal tumour etc
Thus the success rate of the gasless adhesiolysis with spray gel in patients being adhesion and pain free is about 90%.

For Photos of Our Technique of Gasless Adhesiolysis With Spray Gel Click On The Links Below

And images with SprayGel™ in our Endoscopy Atlas Severe bowel adhaesions & Extremely severe bowel adhesions

WHAT IS SECOND LOOK AND THIRD LOOK LAPAROSCOPY FOR ADHESIONS?

SECOND LOOK LAPAROSCOPY (SLL)

The principle of SSL was first introduced by Swolin to evaluate the result of some surgical procedures.

This principle soon became a routine used by many gynecological surgeons and investigators allowing a chance to perform adhesiolysis for the de novo or recurrent adhesions encountered during SLL.

Dr. Daniel Kruschinski is one of the very few surgeons in the world, who performs a second look laparoscopy (SLL) about seven days after the initial surgical procedure.

In Dr. Kruschinski’s experience the risk of adhesions resulting in the need for a subsequent surgery is greatly reduced.

He has mastered the required advanced microsurgical laparoscopic techniques and has logged thousands of hours in performing very difficult, time-consuming, risky surgical procedures.

Repeat surgery for adhesions in these cases is usually less extensive and does not usually involve the same amount of dissection that led to the formation of adhesions in the first place.

The same was shown by Jansen, who reported that second-look laparoscopy resulted in a significant reduction in adhesions at the time of a “third-look laparoscopy”.

Trimbos-Kemper reported a reduction in the incidence of ectopic pregnancy in women who had undergone SLL, although the intrauterine pregnancy rate was unchanged.

Surry and colleagues reported a 52.1% intrauterine pregnancy in 31 patients who had undergone early SLL after reconstructive pelvic surgery.

Other potential advantages of second-look laparoscopy include the ability of the surgeon to assess the efficacy of surgical techniques or adjuvants, as well as to provide the patient a reasonable assessment of likely prognosis.

If the patient is among the approximately ten percent of subjects in whom adhesions worsen, that patient may benefit from early referral to ART as opposed to protracted lengths of time spent trying to conceive against very long odds.

THIRD LOOK LAPAROSCOPY

Dr Kruschinski offers a third look laparoscopy to patients whom are symptomatic even after 3 months of second look laparoscopy.

Surgeon sees an improvement of the adhesion score as a success, whereas the patient often sees an improvement of symptoms or a complete disappearance of symptoms as a success!

After surgery some adhesions may return, the surgeon might measure the reduction of adhesions as an improvement while the patient says s(h)e has pain and therefore concludes the adhesions are back!

In some cases there may be a huge improvement of adhesions (by 99%), but some small adhesions might have formed somewhere and cause extreme pain.

Hence , a third look laparoscopy will help identify these small adhesions but which cause symptoms and will most importantly treat them.

Trimbos-Kemper and co-workers went to further “third-look laparoscopy” in patients who had undergone an early second-look procedure with adhesiolysis at that time. They reported that more than half of the adhesions that were separated at the second-look laparoscopic procedure did not recur.

Different Examples

Left pelvic and abdominal wall adhesions


Left pelvic brim and anterior abdominal wall, omental and bowel adhesions	Another view to show the bowel involvement

After first dissection of adhesions, bowel involvement	The left pelvic brim and the anterior abdominal wall after dissecting the adhesions

The left pelvic brim and the anterior abdominal after application of SprayGel™	The left pelvic brim and the anterior abdominal at the second-look laparoscopy on day 7 postoperative

Adhesions Treatment

informer — Tue, 10 May 2011 07:37:38 +0000

WHAT IS THE NON-SURGICAL TREATMENT OF ADHESIONS?

Medication can play a crucial role in controlling pain – whether acute or chronic.

For acute pain, medication is often the first treatment choice.

For chronic pain, it may serve as part of a broader treatment package.

This could include exercise, physical therapy and behavior change.

Although they can be helpful, medications aren’t a cure-all and can cause side effects or be ineffective and costly.

The best alternative to surgery is to seek the help of a pain specialist.

Only a pain specialist has the specialized training needed to treat chronic pain.

Their specialized training enables them to offer a variety of pain management techniques that are known to be effective for managing chronic pain.
The specialty of Pain Medicine is concerned with the prevention, evaluation, diagnosis, treatment, and rehabilitation of painful disorders. Such disorders may have pain and associated symptoms arising from a discrete cause, such as postoperative pain or pain associated with a malignancy, or may be syndromes in which pain constitutes the primary problem, such as neuropathic pains or headaches.

The diagnosis of painful syndromes relies on interpretation of historical data; review of previous laboratory, imaging, and electrodiagnostic studies; behavioral, social, occupational and avocational assessment; interview and examination by the pain specialist; and may require specialized diagnostic procedures, including central and peripheral neural blockade or monitored drug infusions.

The special needs of the pediatric and geriatric populations are considered when formulating a comprehensive treatment plan for these patients..

The pain physician serves as a consultant to other physicians but is often the principal treating physician and may provide care at various levels, such as direct treatment, prescribing medication, prescribing rehabilitative services, performing pain relieving procedures, counseling of patients and families, direction of a multidisciplinary team, coordination of care with other healthcare providers and consultative services to public and private agencies pursuant to optimal healthcare delivery to the patient suffering from a painful disorder.

The pain physician may work in a variety of settings and is competent to treat the entire range of painful disorders encountered in delivery of quality health care.

The treatment of chronic pelvic pain is a multidisciplinary specialty.

A team of nurses, psychotherapists, physical therapists, pain specialists, anesthesiologists, urologists, gynecologists and general surgeons working in a coordinated manner can mean maximum benefit for the patient.

Not only is the problem of pelvic pain is receiving the attention is deserves, but the team approach to its management is being recognized as one with merit..

Pain mapping is an emerging technique where, under local anesthetic, the surgeon attempts to locate the focus of pain by prodding different areas within the pelvis.

Sometimes pain is associated with adhesions, and sometimes adhesions (or even loci of endometriosis) do not appear responsible for the pain. If an endometriosis site is discovered and removed, this should be covered with an adhesion barrier.

WHAT IS THE SURGICAL MANAGEMENT OF ADHESIONS?

No longer can the public ignore the benefits of minimally invasive surgery for adhesions.

While these techniques and procedures are not without risk, patients should not be denied the procedures’ inherent advantages.

Patients with symptomatic adhesions usually want minimally invasive therapy.

While the advantages of laparoscopic enterolysis compared with classical laparotomy has not been proven in studies, it is obviously possible with laparoscopy to diminish peritoneal mesothelial cell ischemic damage from trauma, drying, talc, packs and delayed bleeding.

Laparoscopic surgery is distinctly advantageous as the preferred method of access for infertility surgery due to the decreased risk of de novo adhesion formation. Similar surgical outcomes when compared to laparotomy have been demonstrated in the management of endometriosis and extensive adhesions.

The surgical advantages of laparoscopy include panoramic pelvic visualization and magnification, techniques similar to microsurgery, documentation of absolute hemostasis via underwater examination.

Finally, the patient enjoys simultaneous diagnosis and treatment and all the advantages of minimally invasive surgery in terms of cosmetics and rapid recuperation.

Laparascopic Adhesiolysis

Although laparoscopic adhesiolysis can be very time-consuming (2 to 4 hours), and for the surgeon technically difficult, many women are discharged on the same day of the procedure, avoid major abdominal incisions, experience minimal complications and return to full activity within one week of the procedure.

The extent, thickness and vascularity of adhesions varies widely.

Intricate adhesive patterns exist with fusion to parietal peritoneum and/or various meshes.

Peritoneal adhesiolysis is classified into enterolysis, which includes omentolysis and female reproductive reconstruction (salpingo-ovariolysis and cul-de-sac dissection with excision of deep fibrotic endometriosis).

Bowel adhesions are divided into:
* Upper Abdominal
* Lower Abdominal
* Pelvic
* Combinations of the Above

Adhesions surrounding the umbilicus are upper abdominal as they require an upper abdominal laparoscopic view for division.

In cases of pelvic adhesions, either the tube is stuck to the ovary or the ovary is adhered to the pelvic sidewall. The rectosigmoid (the rectum and sigmoid colon) may cover both. Rarely, the omentum (a fold of peritoneum extending from the stomach to adjacent organs in the abdominal cavity) and small bowel are involved.

Pelvic adhesiolysis

One of the indicator of the degree of severity and expertise necessary for adhesiolysis is the number of previous laparotomies.

The frequency of small bowel obstruction symptoms also indicates the need for surgery.

SURGICAL PLAN FOR ADHESIOLYSIS

A well defined strategy is important for adhesiolysis.

In general, cases are divided into three parts:

1.) Division of all adhesions to the anterior abdominal wall parietal peritoneum. Small bowel loops encountered during this process are separated using their anterior attachment for countertraction instead of waiting until the last portion of the procedure (running of the bowel).

2.)Division of all small bowel and omental adhesions in the pelvis. The rectosigmoid, cecum and appendix often require some separation during this part of the procedure.

3.)Running of the bowel. Using atraumatic grasping forceps and (usually) a suction irrigator for suction traction, the bowel is run.

4.). Tubo-ovarian pathology is then treated if indicated.

With minimally invasive surgical approaches, same-day discharge is common, even after long procedures.

Physical motility of the bowel is encouraged by early ambulation and a clear liquid diet for 2 to 4 days.

Patients are instructed to return gradually to their normal activity during the week after surgery.

Partial small-bowel obstruction during the week after surgery is usually due to ileus and is treated by intravenous hydration and a nasogastric tube if vomiting is present.

If peritonitis occurs in the days after the operation, it must be assumed that an injury to the bowel has gone unnoticed and should be aptly treated.

If an abscess forms postoperatively it can be drained percutaneously under sonographic guidance, or possibly by means of a laparoscopy.

Recurrent adhesions may occur even with atraumatic techniques

WHAT CAN BE DONE TO PREVENT ADHESIONS?

Although there is no way to eliminate the risk of adhesions completely, there are steps your surgeon can take to reduce the likelihood of adhesion formation.

The most effective methods of adhesion prevention involve meticulous surgical technique and the use of a physical barrier to separate tissue surfaces while they heal.

MICROSURGICAL TECHNIQUES

Surgeons have developed microsurgical techniques that minimize trauma, ischemia, foreign bodies, hemorrhage, raw surfaces and infection to reduce adhesion formation.

Minimally invasive techniques such as the laparoscopy, that are designed to minimize trauma, blood loss, infection, and the introduction of foreign bodies, all of which can lead to inflammation and adhesion formation.

Good surgical technique involves minimizing tissue handling, using delicate instruments, and keeping the tissues moist when they are exposed to the air.

Surgical techniques that can help decrease adhesion formation

Achieve meticulous hemostasis
Maintain vascularity
Moisten tissues
Avoid dry sponges
Minimize tissue handling
Use fine, non-reactive sutures
Avoid peritoneal grafts
Minimize foreign bodies

Not simply the surgical procedure used, but in combination with these techniques and the minimal invasive surgery, i.e. laparoscopy, one has the best chance of adhesion reduction when used in combination.

While good surgical technique is important, but it is often not sufficient to prevent adhesions.

Even though the most meticulous surgical and microsurgical techniques cannot eliminate the formation of adhesions, the other steps can be taken to reduce adhesion formation further are:

Achieve meticulous hemostasis: Inadequate hemostasis and the resultant fibrin deposition promote adhesion formation.
Maintain vascularity: Limiting ischemia supports fibrinolysis.
Moisten tissues:Frequent irrigation and the use of moist sponges prevent desiccation of tissue.
Ringer’s lactate or other irrigating solutions also eliminate any residual talc, lint, or blood clots, which may provide a nidus for a foreign body reaction, inflammation, and adhesion formation.
Avoid dry sponges: Use of gauze and dry sponges should be avoided because they may damage the peritoneal surface and leave a foreign body behind.
Minimize tissue handling:Manipulating tissue increases the possibility of vascular and tissue damage.When direct manipulation of the peritoneum is necessary, use either atraumatic instruments or fingers.In addition, cutting and coagulating should be kept to a minimum to reduce the possibility of trauma and maintain vascularity.
Use fine, nonreactive sutures:To minimize foreign body reactions use the smallest size of suture composed of synthetic material.
Avoid peritoneal grafts:Grafting increases the risk of peritoneal trauma while decreasing vascularity.
Minimize foreign bodies: Foreign bodies may damage the peritoneal surface, lead to inflammation, and ultimately result in adhesion formation.

Chemical Methods

Various drugs have been evaluated in an effort to reduce the post-operative incidence of adhesions.

To date, no well-controlled study has documented the efficacy of these drugs.

Barrier Methods

The use of a barrier between raw tissue surfaces appears to be one of the most promising methods of adhesion prevention.

Barriers mechanically separate the surgical surfaces and keep those surfaces apart.

WHAT ARE THE DIFFERENT TYPES OF ADJUVANTS USED TO PREVENT ADHESIONS?

Adhesion formation and reformation are still an unavoidable event in reproductive pelvic surgery in spite of the variable skills in microsurgery and endoscopic surgery.

This fact necessitates the search for barrier that can be used in the perioperative period.

There have various barriers or adjuvants that have been used but none have conclusively proven to be effective in various studies.

CLASSES OF ADHESION-REDUCTION ADJUVANTS AND THEIR PROPOSED MECHANISM OF ACTION

I. Fibrinolytic agents (fibrinolysis, stimulation of plasminogen activators)
Fibrinolysin
Streptokinase
Urokinase
Hyaluronidase
Chymotrypsin
Trypsin
Pepsin
Plasminogen activators

II. Anticoagulants (prevention of clot and fibrin formation)
Heparin
Citrates
Oxalates

III. Anti-inflammatory Agents (reduce vascular permeability, reduce histamine release and, stabilize lysozomes)

Corticosteroids
Nonsteroidal anti-inflammatory agents
Anti-histamines
Progesterone
Calcium channel blockers
Colchicine

VI. Antibiotics (prevent infection)
Tetracyclines
Cephalosporins

V. Mechanical Separation (surface separation, hydroflotation)

A. Intra-abdominal Instillates:
Dextran
Mineral oil
Silicone
Vaseline
Crystalloid solutions
Carboxymethylcellulose
Hyaluronic acid
Chelated hyaluronic acid
Poloxamer

B. Barriers:
Endogenous tissues:
Omental grafts
Peritoneal grafts
Bladder strips
Fetal membranes
Exogenous materials:
Fibrin glue
Polytetrafluoroethylene
Oxidized cellulose
Oxidized regenerated cellulose
Gelatin
Rubber sheets
Metal foils
Plastic hoods

Modified from Diamond MP, DeCherney AH: Pathogenesis of adhesion formation/reformation: Application to reproductive pelvic surgery. Microsurgery 1987: 8: 103 and Diamond MP, Hershlag A: Adhesion formation/reformation: in Treatment of postsurgical Adhesions, Wiley-Liss, Inc. 1990: 23-33.

Diagnosis for adhesions

informer — Tue, 10 May 2011 07:35:55 +0000

HOW ARE ADHESIONS DIAGNOSED?

When the chronic pain of adhesions is involved, it is very difficult to be diagnosed correctly.
Diagnostic tests such as blood tests, X-ray procedures, CT scans, MRIs, and Ultrasound will notdiagnose adhesions.
However, your doctor will have to rule out other medical conditions; and depending upon your symptoms, your doctor will order the appropriate diagnostic tests.
If the results of these tests are normal or negative for abnormal pathology, then a diagnostic laparoscopy may be appropriate.
A diagnostic laparoscopy is the only test that can confirm the presence of adhesions and/or endometriosis.
However, a diagnostic laparoscopy can be a “Catch 22 situation“; because surgery itself can cause adhesions to form.
Doctors typically diagnose adhesions during a surgical procedure such as laparoscopy (putting a camera through a small hole into the stomach to visualize the organs).
If they find adhesions, doctors usually can release them during the same surgery.
Studies such as blood tests, x-rays, and CT scans may be useful to determine the extent of an adhesion-related problem.
However, a diagnosis of adhesions usually is made only during surgery.
A physician, for example, can diagnose small bowel obstruction but cannot determine if adhesions are the cause without surgery.

Symptoms of adhesions

informer — Tue, 10 May 2011 07:32:32 +0000

WHAT ARE THE SYMPTOMS OF ADHESIONS?

Adhesions in the abdomen pull on parts of the intestines and sometimes cause an obstruction.

Symptoms may include:

pain
cramps
intermittent vomiting
difficulty with passing gas or having a bowel movement
swelling of the abdomen

Symptoms vary depending on the tissues involved.

For example, in the gastrointestinal tract, bowel obstructions may occur.

Mechanical small bowel obstruction after previous surgery can be the most severe effect of adhesions.

In the uterus and in the pelvis, adhesions can cause infertility and other reproductive problems. The adhesions can block the ends of the fallopian tubes causing infertility.

Doctors associate signs and symptoms of adhesions with the problems an adhesion causes rather than from an adhesion directly.

As a result, people experience many complaints based on where an adhesion forms and what it may disrupt.

Typically, adhesions show no symptoms and go undiagnosed. These adhesions cause no problems at that moment , but they can obstruct the intestine in about 2 percent of all patients. These obstructions can occur several years later.

Most commonly, adhesions cause pain by pulling nerves, either within an organ tied down by an adhesion or within the adhesion itself.

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.
It is important to note that not all pain is caused by adhesions and not all adhesions cause pain.
Small bowel obstruction (intestinal blockage) due to adhesions is a surgical emergency.
- These adhesions trigger waves of cramplike pain in your stomach. This pain, which can last seconds to minutes, often worsens if you eat food, which increases activity of the intestines.
- Once the pain starts, you may vomit. This often relieves the pain.
- Your stomach may become tender and progressively bloated.
- You may hear high-pitched tinkling bowel sounds over your stomach, accompanied by increased gas and loose stools.
- Fever is usually minimal.
Such intestinal blockage can correct itself.

However, you must see your doctor. If the blockage progresses, these conditions may develop:

Your bowel stretches further.
Pain becomes constant and severe.
Bowel sounds disappear.
Gas and bowel movements stop.
Your belly will grow.
Fever may increase.
Further progression can tear your intestinal wall and contaminate your abdominal cavity with bowel contents

Intra-abdominal adhesions are usually the result of surgical or gynecologic operations, pelvic inflammatory disease (gonococcal or chlamydial), appendicitis or endometriosis.

Adhesions may be responsible for chronic persistent abdominal pain without associated pelvic pathology.

Though adhesions probably cause pain by entrapment of expansile viscera, the relationship of adhesions to abdominal pain is still controversial.

In contrast, mechanical small bowel obstruction after previous surgery demonstrates unequivocally the most severe effect of adhesions.

Patients with chronic or recurrent abdominal pain and a history of numerous abdominal surgical procedures are often denied treatment if they are not obstructed or symptomatic of intermittent bowel obstruction.

WHAT IS ADHESIONS RELATED DISORDER (ARD)?

Adhesion related disorder is a complex of symptoms related to adhesions.

Patient’s primary complaint is usually chronic abdominal pain.

Their symptoms can be primarily in one area of the abdomen but are often generalized, vague, crampy and difficult to define.

The symptoms of ARD could include:

Chronic pain
Infertility
Bowel obstruction
Gastro-esophageal reflux disease, (GERD)
Urinary Bladder dysfunction
Pain and difficulty having a bowel movement
Pain on movement such as: Walking, sitting or laying in certain positions.
Loss of Nutrients due to poor eating habits or loss of appetite.
Loss of employment due to lost work days
Loss of family and social life
Emotional Disorders such as: Depression, Thoughts of Suicide, Hopelessness

Other intestinal problems can accompany the pain.

Constipation or obstruction is sometimes encountered.

Alternating constipation with diarrhea from partial obstruction can also be seen.

Symptoms may also be related to the gynecologic orders in women as this disorder frequently affects women.

Changes in the menstrual cycle, infertility, and pain with sexual intercourse can be encountered.

Other symptoms, not directly related to the adhesions, can also be encountered.

Since ARD generally results in chronic problems, anxiety and depression can result.

Strained relationships can occur especially when the disorder affects sexual function.

Difficulty with conception can result.

This further adds to the anxiety and problems with self esteem experienced by women who suffer with this disorder.

Difficulty eating can result in poor nutrition, weakening suffers overall medical condition and can also lead to a decrease in immune function leading to many other illnesses.

Since many of the symptoms related to ARD are vague and wide spread and often include emotional factors, they are often difficult to diagnose.

Symptoms of ARD will often be attributed to other abnormalities.

Patient will often carry multiple diagnoses including chronic fatigue syndrome, endometriosis, irritable bowel syndrome, fibromyalgia, depression, anxiety, along with a whole host of other possible syndromes.

While multiple disorders can certainly exist in one patient, the confusion over which abnormality is truly causing the symptoms adds to the frustration of ARD. This, unfortunately, adds to the discomfort experienced by those who suffer with adhesions.

Undiagnosed chronic pain causes so much physical and emotional pain for victims of adhesion related disorder – and fills their lives with so much indecision.

In time the effects of ARD will begin to affect the lives of their families, their relationships and their jobs. This inordinate control by ARD has the power to erode and change our lives – and not necessarily for the better!

It is so important to believe in yourself, trust the feelings you have about your pain, and tell it like it is. You have the right to be listened to and treated with respect – nothing less!!

HOW DO ADHESIONS CAUSE CHRONIC PELVIC PAIN (CPP) ?

Many women are held captive by a recurring or constant pain in the abdomen. The pain can be intense and sometimes debilitating. It may last for months or even years, leading some women to jump from physician to physician in search of a cure.

Chronic pelvic pain is defined as a pain in the pelvic or lower abdomen area, not related to the menstrual cycle, which persists for six months or more. Because of its vague and inconsistent symptoms, chronic pelvic pain is difficult to diagnose. But it is real, and in most cases it can be treated.

There may be one factor causing the pain or there may be many. If the pain is gynecological, it could be caused by such conditions as pelvic adhesions, endometriosis, or pelvic inflammatory disease.

Adhesions are believed to cause pelvic pain by tethering down organs and tissues, causing traction (pulling) of nerves. Nerve endings may become entrapped within a developing adhesion. If the bowel becomes obstructed, distention will cause pain.

Some patients in whom chronic pelvic pain has lasted more than six months may develop “Chronic Pelvic Pain Syndrome.” In addition to the chronic pain, emotional and behavioral changes appear due to the duration of the pain and its associated stress.

According to the International Pelvic Pain Society:

“We have all been taught from infancy to avoid pain. However, when pain is persistent and there seems to be no remedy, it creates tremendous tension. Most of us think of pain as being a symptom of tissue injury. However, in chronic pelvic pain almost always the tissue injury has ceased but the pain continues. This leads to a very important distinction between chronic pelvic pain and episodes of other pain that we might experience during our life: usually pain is a symptom, but in chronic pelvic pain, pain becomes the disease.”

Chronic pelvic pain is estimated to affect nearly 15% of women between 18 and 50 (Mathias et al., 1996).

Other estimates arrive at between 200,000 and 2 million women in the United States (Paul, 1998).

The economic effects are also quite staggering. In a survey of households, Mathias et al. (1996) estimated that direct medical costs for outpatient visits for chronic pelvic pain for the U.S. population of women aged 18-50 years are $881.5 million per year. Among 548 employed respondents, 15% reported time lost from paid work and 45% reported reduced work productivity.

Not all ADHESIONS cause pain, and not all pain is caused by ADHESIONS.

Not all surgeons, particularly general surgeons, agree that adhesions cause pain.

Part of the problem seems to be that it is not easy to observe ADHESIONS non invasively, for example with MRI or CT scans.

However, several studies do describe the relationship between pain and adhesions.

According to an early study (Rosenthal et al., 1984) of patients reporting CPP, about 40% have adhesions only, and another 17% have endometriosis (with or without adhesions).

Kresch et al., (1984) also studied 100 women and found ADHESIONS in 38% of the cases and endometriosis in another 32%.

Overall estimates (Howard, 1993) of the percentage of patients with CPP and ADHESIONS is about 25%, with endometriosis accounting for another 28%. These figures must be understood in their context.

It is important to recognize that emotional stress contributes greatly to the patients perception of pain and her/his ability to deal with the pain.

Rosenthal et al. (1984) found that of the patients in whom a possible physical cause of pain (including ADHESIONS) could be identified, 75% had evidence of psychological influences on the pain.

Because pelvic pain can be caused by a myriad of disorders, it is important to find a doctor who is sensitive to your needs and willing to take the time to solve the problem. Don’t let anyone dismiss it as being ” all in your head.”. The solution may require time and energy, but most causes of pelvic pain can be treated successfully.”

Causes of adhesions

informer — Tue, 10 May 2011 07:30:38 +0000

WHAT ARE THE CAUSES OF ADHESIONS IN GYNAECOLOGICAL AND ABDOMINAL SURGERY?

Adhesions may form as the result of the following common gynaecologic procedures:

Ovarian Surgery:
The ovary is the most common site for adhesions to form, usually resulting from surgery to remove ovarian cysts.

Surgical Treatment of Endometriosis:
Endometriosis is a disease in which patches of endometrial tissue – the mucous membrane that lines the inside of the uterus – become implanted outside the uterus. Endometriosis often occurs in the pelvis and abdomen and can be associated with severe inflammation and dense adhesions. The abnormal tissue is removed through surgery.

Myomectomy
Myomectomy is the removal of fibroids from the uterus. Adhesion formation at the incision line on the uterus is a common complication of the procedure.

Adhesiolysis
Adhesiolysis is the removal or surgical separation of adhesions. Ironically, the removal of adhesions can aggravate the healing process, thereby leading to the formation of new adhesions.

Reconstructive Tubal Surgery:
The repair of blocked fallopian tubes is a delicate procedure that often includes the removal of existing adhesions. Unfortunately, the surgery itself can lead to the formation of new adhesions.

Adhesions also are a common occurrence in women who suffer from pelvic inflammatory disease (PID) and sexually transmitted diseases.

Factors that contribute to the cause of adhesions include the following:

Trauma:
The healing process from surgery is a major contributor to adhesion formation.

Ischemia:
During surgery, blood flow is often disrupted as a result of tissue cutting, blood clotting or tying of stitches. This may result in ischemia, or reduction of blood flow to the tissues, therefore contributing to adhesion formation.

Foreign Bodies:
Foreign bodies include stitches, lint from sponges or talc from surgical gloves. Foreign bodies can cause an inflammatory reaction in the body and can trigger adhesion formation.

Inflammation:
Endometriosis and PID can cause inflammation, which can result in adhesion formation.

Adhesions following abdominal surgery

Abdominal surgeries that could lead to adhesions include

colectomy,
hernia repair
adhesiolysis for bowel obstruction.
Appendectomy
Cholecystectomy
Cancer surgery
Liver and spleen surgery

Adhesions have been documented to occur in up to 94% of patients after major abdominal surgery

WHAT ARE THE DIFFERENT TYPES OF ADHESIONS ?

The tissue develops when the body’s repair mechanisms respond to any tissue disturbance, such as surgery, infection, trauma, or radiation.

Although adhesions can occur anywhere, the most common locations are within the abdomen, the pelvis, and the heart.

Pelvic adhesions:

Pelvic adhesions may involve any organ within the pelvis, such as the uterus, ovaries, fallopian tubes, or bladder, and usually occur after surgery.
Adhesions between anterior uterine wall

Adhesions between uterus ,adnexa and bowel posteriorly
Pelvic inflammatory disease (PID) results from an infection (usually a sexually transmitted disease) that frequently leads to adhesions within the fallopian tubes.
A woman’s eggs pass through her fallopian tubes into her uterus for reproduction.
Tubal adhesions can lead to infertility and increased incidence of ectopic pregnancy in which a fetus develops in the tube.

Abdominal adhesions:

Abdominal adhesions are a common complication of surgery, occurring in up to 93% of people who undergo abdominal or pelvic surgery.
Abdominal adhesions also occur in 10.4% of people who have never had surgery.
Most adhesions are painless and do not cause complications.
However, adhesions cause 60%-70% of small bowel obstructions in adults and are believed to contribute to the development of chronic pelvic pain.
Bowel adhesions
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.

De novo adhesions

De novo are new adhesions that may form at a site of direct surgical trauma such as an incision.
They may also develop at locations away from the site of surgery, for example, around the adnexa at the time of a cesarean section.
Adhesions may also reform following adhesiolysis or adhesiectomy.

Three broad types of adhesions exist, but the underlying pathophysiology is similar for each:

Filmsy
Vascular
Cohesive

About Adhesions

informer — Tue, 10 May 2011 06:36:08 +0000

WHAT ARE ADHESIONS ?

Adhesions are one of the best hidden secrets or enigmas of modern medicine

The word adhere literally means to stick or to bind together.

When tissue that is normally not connected grows together, it is called an adhesion. It is also commonly referred to as scar tissue.

Adhesions are fibrous tissues (scar tissue) that cause organs within the body to adhere to other internal organs that are not normally connected.

Adhesions may appear as thin sheets of tissue similar to plastic wrap or as thick fibrous bands.

Adhesions may involve the female reproductive organs (ovaries, Fallopian tubes) can and do cause infertility, dyspareunia (painful intercourse) and debilitating pelvic pain. Adhesions involving the bowel can cause bowel obstruction or blockage.

Adhesions may form elsewhere such as around the heart, spine and in the hand where they lead to other problems.

HOW COMMON IS THE PROBLEM OF ADHESIONS?

Adhesions are a widespread problem and develop following any type of pelvic or abdominal surgery.

The rate of adhesion formation after surgery is surprising given the relative lack of knowledge about adhesions among doctors and patients alike.

Adhesions have been shown to develop in up to 93% of surgical patients.

This number increased in patients with major and multiple procedures respectively.

Similarly, some studies found that 93% of patients who had undergone at least one previous abdominal operation had adhesions, compared with only 10.4% of patients who had never had a previous abdominal operation.

The incidence of adhesions has increased with the rise in gynaecological procedures.

It has been shown that between 60 to 90 % of women suffer post operative adhesions following major gynaecological surgery.

WHAT IS THE IMPACT OF ADHESIONS ON PATIENTS AND SURGEONS?

The Impact of Adhesions on Patients:

Adhesive Disease accounts for 49-74% of small bowel obstructions.
Adhesive Disease accounts for 15-20% of infertility cases.
Adhesive Disease accounts for 20-50% of chronic pelvic pain cases.
Reduced quality of life.
Loss of work days and productivity
Increased risk, complexity and complications during subsequent surgery.
One study showed a 19% rate of adhesion-related bowel perforation during subsequent/secondary operations.
Bowel perforations occur even more frequently (33%) during surgery for SBO.
Patients with adhesion-related perforations had significantly higher postoperative complications (leaks, wound infections, hemorrhages and length of stay).

The Impact of Adhesions on Surgeons:

Increased reoperative times
Increased risk of enterotomy
Increased level of surgical complexity

HOW DO ADHESIONS OCCUR?

Rarely adhesions are present from birth.

Adhesions commonly form in the abdominal-pelvic cavity as a result of inflammation, injury or following surgery – as part of the body’s completely natural and normal healing process.

Usually they occur as part of the healing that takes place after surgery, particularly abdominal surgery.

Adhesions can also form after inflammation in the abdomen or pelvis.

Adhesions develop as the body attempts to repair itself. This normal response can occur after surgery, infection, trauma, or radiation.

Repair cells within the body cannot tell the difference between one organ and another. If an organ undergoes repair and comes into contact with another part of itself, or another organ, scar tissue may form to connect the 2 surfaces.

BIOCHEMICAL EVENTS LEADING TO FORMATION OF ADHESIONS

During the body’s reaction that leads to an adhesion, chemicals called inflammatory mediatorsand histamines are released from the blood (more specifically the blood’s mast cells and leukocytes).
Capillaries dilate. This allows leukocytes, red blood cells and platelets to concentrate at the injury site in a bundle called a fibrinous exudate.
A variety of other factors are at play in the system such as as prostaglandins, bradykinin, chemotactic agents, lymphokines, seretonin and transforming growth factor.
At this point in time fibrinolysis may clear the fibrinousexudate.
In order for this to occur, plasminogen must be converted to plasmin by tissue plasminogen activator (t-PA). There is constant interplay between the t-PA and plasminogen-activator inhibitors.
Unfortunately surgical trauma normally decreases t-PA activity while simultaneously increasing plasminogen activator inhibitors.
If this occurs, the fibrinous exudate is transformed into an organized adhesion where fibers of collagen are deposited.
Blood vessels begin to form, which leads to an adhesion.