All About Adhesions - National Women's Health Resource Center/Healthywomen.org

All About Adhesions
from the National Women's Health Resource Center's Guide to Preparing for Gynecologic Surgery

Any surgical procedure carries a risk of complications. In gynecologic surgery, one of the most common complications is pelvic adhesions. They occur when tissue in the abdominal cavity gets "stuck" to other tissue, similar to how plastic wrap clings to itself. Left untreated, adhesions can cause a variety of problems. These include:

Pelvic pain: An estimated 38 percent of women suffering from pelvic pain have adhesions. This pain occurs because adhesions bind normally separate organs and tissues together. When these tissues are stretched with normal movements throughout the day, nearby nerves are affected, causing pain.
Pain during intercourse: Adhesions can also cause pain during intercourse (a condition called dyspareunia).
Infertility: Adhesions that form as a result of certain types of gynecologic surgery, especially tubal surgeries and surgeries to remove fibroids (myomectomies), are a common cause of infertility. Adhesions between the ovaries, fallopian tubes or pelvic walls can block the passage of the egg from the ovaries into and through the fallopian tubes. Adhesions around the fallopian tubes can also make it difficult or impossible for sperm to reach the egg.
Bowel obstruction: Adhesions involving the bowel are particularly common after abdominal hysterectomy. While these adhesions don't normally result in any problems, one serious problem that may develop is intestinal or bowel obstruction (blockage of the intestine that limits or stops passage of its contents). This problem may occur a few days or many years after surgery. Symptoms include pain, nausea and vomiting.

Adhesions are common after all forms of gynecologic surgery, particularly those that require an abdominal incision. They are a particular risk for women who have more than one cesarean section. One study found that women having their third or more cesarean section were almost twice as likely to experience dense adhesions as those undergoing their second (46.1 percent vs. 25.6 percent). Both groups, however, experienced a significant rate of adhesions.

Even after adhesions are removed, they tend to reoccur 80 percent of the time. That's why it's so important that you talk to your surgeon about adhesions and ways to prevent them from forming during surgery.

All surgeons know about the risks of adhesions, so they try their best to reduce this risk. The most important thing they can do is limit any injury of the peritoneum, the membrane that covers the inside of the abdomen. When healthy, this membrane is slippery. Once injured, however, the immune system kicks in to repair things, leading to inflammation and the production of sticky scar tissue that can lead to adhesions. This is particularly important during a cesarean section; several studies find that closing the peritoneum after a woman's first caesarian section significantly reduces the risk of adhesions in subsequent cesarean's.

Surgeons can also reduce the risk of adhesions by using certain sutures; carefully removing any dead tissue; handling all tissue very gently; reducing the inflammatory response; and/or creating barriers between damaged tissues so they don't stick. Today there are several approved devices, gels or other substances surgeons can use as "adhesion barriers."

The type of surgical procedure used also makes a difference in whether or not adhesions form. Adhesions are more common with laparotomies than laparoscopic procedures because laparotomy causes more tissue damage. In fact, some studies find postoperative adhesions in up to 94 percent of women undergoing open abdominal surgery.

Minimally invasive laparoscopic surgeries, however, carry less risk of infection. They also involve more precise tissue manipulation, result in less contamination with foreign bodies and help maintain tissue moisture better than abdominal surgery. Still, even laparoscopic procedures have high rates of adhesions: up to 70 percent after laparoscopic procedures to remove fibroids.