Causes of adhesions

May 10, 2011

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
    •  

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