Surgical Adhesions from Gynecologic Surgery

When you're headed for hysterectomy or other gynecologic surgery, you are probably worried about many things. Will you have any bad reactions to the anesthesia? Will the surgeon find any major problems? Will you be in much pain? Will recovery be fast? One thing you probably don't think about, however, is whether the surgery will cause pelvic or abdominal adhesions—a complication that could cause health problems for you in the future.

Yet adhesions, which occur when bands of scar tissue in the abdominal cavity get "stuck" to pelvic or abdominal organs, are one of the most common complications of pelvic and abdominal surgeries. The type of surgery doesn't matter; although adhesions are slightly less likely to occur with laparoscopic surgery (in which a surgeon makes very small incisions in the abdomen instead of one large incision) they still occur at a fairly high rate.

Adhesions form as a result of injury or trauma to the peritoneum, the clear membrane that covers the inside of the abdomen and all abdominal and pelvic organs, except the ovaries. 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 called a fibrin matrix.

Normally these bands of scar tissue dissolve through a biochemical process called fibrinolysis, just like a cut on your finger and any resulting scab eventually heal. But surgery reduces levels of blood chemicals needed for fibrinolysis, meaning these fibrous brands may not dissolve; instead, they develop into adhesions. They may form within a couple of weeks after surgery or not for months or even a year or more.

Although all gynecologic and abdominal surgeries can cause adhesions, cesarean sections, particularly repeat cesarean sections, carry a very high risk. 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.

Although many women develop adhesions after surgery and never know it, in some women adhesions can cause serious complications, including:

• Pelvic pain: One study found that 82 percent of 224 patients suffering from chronic abdominal pain had adhesions and no other disease. Other studies find that adhesions are the most common reason for chronic pelvic pain in women. This pain occurs because adhesions bind together normally separate organs and tissues. As you move throughout the day, these tissues stretch, affecting nearby nerves and 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 prevent an egg from the ovaries from getting into and through the fallopian tubes. Adhesions around the fallopian tubes may make it difficult or impossible for sperm to reach the egg. One study found adhesions in 37 percent of 733 infertile women; in 41 of these women, adhesions were the only reason for their infertility. Overall, some experts suspect that pelvic adhesions may be responsible for up to 40 percent of infertility.
• Bowel obstruction: Adhesions are one of the leading causes of intestinal blockages, responsible for 30 to 60 percent of all cases. Such obstruction limits or stops passage of feces through the intestines, leading to pain, nausea and vomiting, possibly resulting in infection and additional surgery.

Adhesions can also make other abdominal surgeries longer and more challenging. For instance, they may make it impossible to perform a laparoscopic procedure, meaning you must undergo an open abdominal incision, which typically has a greater risk of complications and pain and requires a longer recovery time.

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. Surgeons can also reduce the risk of adhesions by:

• Using certain sutures found to be less likely to cause adhesions.
• Administering medications to reduce inflammation.
• Creating barriers between damaged tissues so they don't stick. Today there are several approved devices, liquids, gels, films and other substances surgeons can use as "adhesion barriers." Some have been found to result in adhesions rates at 40 percent or more lower compared to surgeries not using any barrier.
• Closing the peritoneum after a cesarean section. Several studies find this significantly reduces the risk of adhesions during subsequent cesareans.

Minimizing risks for adhesions is the best course since the only way to treat adhesions is to surgically remove them during a procedure called adhesiolysis. Ironically, since the procedure itself damages the peritoneum, it can cause even more adhesions. Plus, adhesions often reform after adhesiolysis.