Pelvic Adhesions

Adhesion refers to the abnormal formation of fibrous bands or scar tissue that can occur in the pelvic or abdominal cavity.

Adhesions in the pelvic and abdominal cavity are most commonly caused by endometriosis, whereas in the past, pelvic inflammatory disease (PID) was believed to be the main cause.

Endometriosis adhesions result in the formation of fibrous bands and scarring that contain endometriosis glands, stroma, and inflammation, which distinguishes them from adhesions caused by repeated surgeries, which typically consist of fibrous bands alone.

(Hic et nunc, 2009). Creative Commons license.

How are Adhesions Formed?

(a) adhesions formed by endometriosis

(b) adhesions secondary to surgery

(d) adhesions secondary to innate pathology

Formation of Adhesions

Adhesions can form due to various causes such as inflammation, infection, trauma, surgery, or endometriosis, resulting in the abnormal formation of fibrous bands or scar tissue in the pelvic or abdominal cavity.

(a) Endometriosis Adhesions

Endometriosis is a condition in which the tissue that normally lines the inside of the uterus, called the endometrium, grows outside of the uterus, typically in the pelvic cavity. This can result in the formation of adhesions, which are fibrous bands or scar tissue that can occur as a secondary response to the inflammatory process associated with endometriosis.

When endometrial tissue implants on pelvic organs, such as the ovaries, fallopian tubes, bladder, or intestines, it can cause irritation, inflammation, and tissue damage. Over time, the body’s healing response may involve the formation of scar tissue or fibrous bands in an attempt to repair the damaged tissue. However, this scar tissue can also stick to nearby organs and tissues, leading to the formation of adhesions.

(b) Adhesions secondary to surgery

Adhesions that occur as a secondary result of surgery are fibrous bands or scar tissue that can form in the abdominal or pelvic cavity as a natural part of the body’s healing response to surgical intervention. Surgery, particularly abdominal or pelvic surgery, can result in tissue trauma, inflammation, and disruption of normal tissue planes, leading to the formation of adhesions during the healing process.

After surgery, the body undergoes a process of tissue repair, which involves the deposition of collagen, a fibrous protein, to help heal the surgical incision or injured tissues. However, in some cases, this healing process can result in the formation of excessive scar tissue or adhesions. Adhesions can develop between organs, tissues, or surfaces that are not normally connected, leading to organs or tissues sticking together or becoming tethered.

(c) Adhesions secondary to infection

Adhesions that occur as a secondary result of infection are fibrous bands or scar tissue that can form in the abdominal or pelvic cavity as a consequence of an infectious process. Infections, particularly those involving the abdominal or pelvic organs, can cause tissue inflammation, damage, and healing responses that may result in the formation of adhesions.

When an infection occurs, the body’s immune system responds by triggering an inflammatory response to fight off the infection. This inflammation can cause damage to tissues and organs, resulting in tissue trauma and healing responses that may involve the deposition of collagen, a fibrous protein, to promote tissue repair. However, in some cases, the healing process can result in the formation of excessive scar tissue or adhesions, leading to organs or tissues sticking together or becoming tethered.

(d) Adhesions secondary to innate pathology

Adhesions that occur as a secondary result of innate pathology refer to fibrous bands or scar tissue that form in the abdominal or pelvic cavity due to inherent or intrinsic factors within the body. Innate pathology refers to internal conditions or factors that are present in the body, often congenital or acquired, and may contribute to the development of adhesions.

There are various innate pathologies that can lead to adhesion formation. For example, certain genetic or hereditary conditions may result in abnormalities in tissue structure or function, making them more prone to forming adhesions. Conditions such as Ehlers-Danlos syndrome, Marfan syndrome, or other connective tissue disorders can affect the strength and integrity of tissues, making them more susceptible to adhesion formation.

Other innate pathologies that can contribute to adhesion formation include autoimmune disorders, chronic inflammation, or metabolic disorders that affect tissue healing and repair processes. For instance, conditions like Crohn’s disease or ulcerative colitis, which are inflammatory bowel diseases, can lead to chronic inflammation and tissue damage in the abdominal cavity, increasing the risk of adhesion formation.

Symptoms of Adhesions

Adhesions can cause a variety of symptoms, depending on their location, size, and extent. Common symptoms of adhesions may include:

Pain: Adhesions can cause localized or referred pain, which may be dull, aching, or sharp in nature. The pain may worsen with movement or certain activities, and may be persistent or intermittent.
Restricted movement: Adhesions can limit the normal movement of organs or tissues in the body, leading to restricted mobility or functional impairments. For example, adhesions in the abdominal or pelvic cavity can cause organs to become “stuck” together, resulting in restricted movement and discomfort.
Digestive symptoms: Adhesions involving the gastrointestinal tract, such as the small or large intestine, may cause symptoms such as bloating, constipation, diarrhea, nausea, or vomiting. Adhesions can also lead to bowel obstruction, which can cause severe abdominal pain, distention, and changes in bowel movements.
Gynecological symptoms: Adhesions related to gynecological conditions, such as endometriosis, can cause symptoms such as pelvic pain, painful menstrual periods, pain during sexual intercourse, and infertility.
Urinary symptoms: Adhesions involving the urinary tract, such as the bladder or ureters, may cause symptoms such as pain or discomfort during urination, frequent urination, urgency, or difficulty emptying the bladder completely.
Complications with surgery or medical procedures: Adhesions can cause complications with subsequent surgeries or medical procedures, such as difficulty in accessing the affected area, increased risk of injury or damage to surrounding organs or tissues, or decreased surgical success rates.
Other symptoms: Adhesions can also cause non-specific symptoms such as fatigue, general discomfort, or changes in body sensations.

It’s important to note that adhesions can be asymptomatic in some cases and may not cause any noticeable symptoms. However, if adhesions are suspected or if they are causing significant symptoms or functional impairments, medical evaluation and management may be needed.

Endometriosis Adhesions Common Locations

Endometriosis adhesions commonly form in the pelvic and abdominal cavity, as endometriosis is a gynecological condition where the tissue that normally lines the uterus (endometrium) grows outside of the uterus. The misplaced endometrial tissue can adhere to nearby organs or tissues, leading to the formation of adhesions.

Some common locations where endometriosis adhesions may form include:

Ovaries: Endometriosis can cause adhesions to form between the ovaries and nearby structures such as the fallopian tubes, uterus, or pelvic sidewalls.
Uterus: Adhesions may form between the uterus and other pelvic organs, such as the bladder or rectum, due to endometriosis.
Pelvic sidewalls: Endometriosis adhesions can form along the sides of the pelvis, causing organs and tissues to adhere to each other and restrict movement.
Cul-de-sac: The cul-de-sac, which is a small pouch located between the uterus and rectum, can be a common site for endometriosis adhesions to develop.
Bowel: Endometriosis adhesions can affect the intestines, leading to adhesions between the bowel loops or between the bowel and other pelvic structures.
Bladder: Adhesions may form between the bladder and other pelvic organs or tissues, resulting in bladder-related symptoms in cases of endometriosis.

It’s important to note that having one or more risk factors does not necessarily mean that a woman will develop fibroids, and many women with fibroids have no identifiable risk factors. The development of fibroids is likely influenced by a combination of multiple factors, and further research is needed to fully understand the complex mechanisms involved in fibroid development.

Diagnosis of Adhesions

Diagnosing adhesions typically involves a comprehensive evaluation by a healthcare professional, such as a gynecologist, general surgeon, or radiologist. Medical history, physical examination, and imaging studies such as ultrasound, MRI, or CT scan may be used to identify the presence of adhesions.

In some cases, diagnostic laparoscopy, a minimally invasive surgical procedure, may be performed to directly visualize and assess the extent of adhesions. During laparoscopy, the surgeon can use specialized instruments to carefully inspect the pelvic and abdominal cavity, identify adhesions, and may also perform adhesion release or removal as part of the diagnostic or therapeutic procedure.

Proper diagnosis of adhesions is important for determining appropriate treatment strategies and managing associated symptoms.

Surgical Methods for the Treatment of Adhesions

The treatment of adhesions depends on various factors such as the location, extent, and severity of the adhesions, as well as the presence of symptoms and the underlying condition causing the adhesions. Here are some common surgical methods for adhesions:

Laparoscopic Surgery (Adhesiolysis)

Laparoscopic adhesion surgery, also known as adhesiolysis, is a minimally invasive surgical procedure that is commonly used to treat adhesions in the pelvic and abdominal cavity. During laparoscopic adhesion surgery, small incisions are made in the abdominal wall, and a laparoscope (a thin, flexible tube with a light and camera) is inserted to visualize the adhesions. Specialized instruments are then used to carefully separate and release the adhesions, allowing the affected organs and tissues to move more freely.

Laparoscopic adhesion surgery offers several advantages over open surgery, including smaller incisions, less postoperative pain, shorter hospital stays, and quicker recovery times. However, it is a technically challenging procedure that requires expertise in laparoscopic techniques, and not all adhesions can be safely and effectively treated laparoscopically, depending on the location, extent, and severity of the adhesions.

After laparoscopic adhesion surgery, additional measures such as adhesion barriers may be used to reduce the risk of adhesions re-forming. Postoperative care typically includes pain management, wound care, and a gradual return to normal activities under the guidance of the surgical team.

Robotic-Assisted Adhesiolysis

Robotic surgery is a minimally invasive surgical approach that uses specialized robotic-assisted surgical systems to perform complex surgical procedures with enhanced precision and control. Robotic surgery has been used in various surgical specialties, including gynecological surgery for the treatment of adhesions.

In the context of adhesion surgery, robotic-assisted techniques can be utilized for adhesiolysis, which is the surgical removal or division of adhesions that have formed in the pelvic or abdominal cavity. Robotic adhesiolysis typically involves the use of a surgical robot, such as the da Vinci Surgical System, which provides the surgeon with enhanced dexterity and visualization, allowing for precise and meticulous dissection of adhesions.

The benefits of robotic adhesiolysis may include reduced postoperative pain, shorter hospital stays, faster recovery, and improved cosmetic outcomes compared to traditional open surgery. However, it’s important to note that the availability and use of robotic surgery, including for adhesion treatment, may vary depending on the healthcare facility, surgeon’s experience and expertise, and individual patient factors.

Adhesions Barrier

Adhesion barriers are medical devices used during surgery to help reduce the formation of adhesions, which are abnormal bands of scar tissue that can form between tissues or organs after surgery or injury. Adhesion barriers work by creating a physical barrier between tissues or organs, preventing them from sticking together during the healing process.

Adhesion barriers may be made of different materials, such as synthetic polymers, collagen, or hyaluronic acid, and may come in the form of sheets, gels, or sprays.

The use of adhesion barriers can help reduce the risk of adhesion formation and potentially decrease the complications associated with adhesions, such as pain, bowel obstruction, and infertility. However, it’s important to note that not all surgical procedures require or benefit from the use of adhesion barriers, and their use should be determined on a case-by-case basis by the surgeon based on the patient’s individual circumstances and the specific surgical procedure being performed.

Pankaj Singhal, MD, MS, MHCM

Master Surgeon in Robotic Surgery

Dr. Pankaj Singhal, a globally recognized endometriosis surgeon, possesses over 25 years of expertise in laparoscopic excision surgery, enabling him to tackle even the most challenging endometriosis cases with confidence. Dr. Pankaj treats patients with diverse endometriosis-related conditions, ranging from ovarian endometriomas to severe deep infiltrating endometriosis that affects the bowels and other organs.

Dr. Pankaj prioritizes minimally invasive surgery and provides comprehensive personal care. Additionally, he is the owner and founder of New York Gynecology and Endometriosis (NYGE), and has dedicated his life to advocating for, respecting, and treating women suffering from this little-known disease. He is one of the few surgeons in the entire United States who have completed over 5,718 robot-assisted gynecologic surgeries.

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Surgeries are typically covered by health insurance. However, the extent of coverage can vary depending on the specific insurance plan and policy. Some insurance plans may cover a broad range of surgical procedures, including both elective and necessary surgeries, while others may have limitations or exclusions for certain procedures.

In some cases, certain insurance plans or programs may fully cover the cost of surgery, leaving the patient with no financial responsibility.

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