What are the common symptoms of pelvic adhesions following a hysterectomy. How can pelvic adhesions impact a woman’s quality of life. What are the treatment options available for managing pelvic adhesions after surgery.

Understanding Pelvic Adhesions: Causes and Formation

Pelvic adhesions are a common yet often misunderstood complication that can occur after various pelvic surgeries, including hysterectomies. These adhesions form when tissues or organs within the pelvic cavity become stuck together during the healing process. But what exactly triggers their formation?

Adhesions typically develop as a result of:

• Inflammatory events (e.g., pelvic infections, endometriosis)
• Surgical procedures (e.g., hysterectomy, ovarian cyst removal)
• Trauma to pelvic tissues
• Chronic irritation from conditions like endometriosis

During the body’s natural healing process, fibrous bands of scar tissue can form between adjacent structures in the pelvis. While this is part of the normal repair mechanism, it can lead to unintended consequences when these structures become tethered together.

The Role of Peritoneum in Adhesion Formation

The peritoneum, a slippery membrane lining the abdominal and pelvic cavities, plays a crucial role in preventing adhesions under normal circumstances. However, when this protective layer is compromised due to surgery or inflammation, it can set the stage for adhesion development.

Do all individuals who undergo pelvic surgery develop adhesions? The answer is no. The likelihood and severity of adhesion formation can vary greatly between individuals. Factors influencing adhesion development include:

• The nature and extent of tissue trauma
• Duration of inflammatory insult
• Surgical technique employed
• Individual healing characteristics

Recognizing Symptoms of Pelvic Adhesions Post-Hysterectomy

Identifying pelvic adhesions can be challenging, as symptoms may not manifest immediately after surgery. In some cases, adhesions remain asymptomatic indefinitely. However, when symptoms do occur, they can significantly impact a woman’s quality of life.

Common symptoms of pelvic adhesions after hysterectomy include:

1. Chronic pelvic pain
2. Painful intercourse (dyspareunia)
3. Pelvic tenderness
4. Bowel obstruction or dysfunction
5. Urinary symptoms
6. Infertility (in cases where ovaries are retained)

Chronic Pelvic Pain and Tenderness

One of the most prevalent symptoms of pelvic adhesions is persistent pain in the lower abdomen or pelvic region. This pain may be constant or intermittent and can vary in intensity. It’s often described as a dull ache or a sharp, stabbing sensation.

Why does chronic pain occur with pelvic adhesions? When organs or tissues become tethered together, it can restrict their natural movement and cause tension on surrounding structures. This tension can lead to ongoing discomfort and pain, particularly during physical activities or certain body positions.

Sexual Dysfunction and Dyspareunia

Painful intercourse, or dyspareunia, is another common complaint among women with pelvic adhesions. The pain can range from mild discomfort to severe pain that makes sexual activity impossible.

How do adhesions contribute to sexual dysfunction? When adhesions form near the vaginal cuff (the area where the cervix was removed during hysterectomy) or involve the ovaries, they can cause pain and discomfort during sexual penetration. Additionally, adhesions may limit the natural mobility of pelvic organs, leading to pain with certain sexual positions.

Gastrointestinal Complications: A Hidden Consequence of Pelvic Adhesions

While pelvic pain and sexual dysfunction are often the most discussed symptoms, gastrointestinal issues can also arise from pelvic adhesions post-hysterectomy. These complications can range from mild discomfort to severe, potentially life-threatening conditions.

Common gastrointestinal symptoms associated with pelvic adhesions include:

• Abdominal bloating and distension
• Constipation or changes in bowel habits
• Crampy abdominal pain
• Nausea and vomiting
• Partial or complete bowel obstruction

Understanding Bowel Obstruction Risk

One of the most serious complications of pelvic adhesions is bowel obstruction. This occurs when adhesions constrict or kink portions of the intestine, impeding the normal passage of bowel contents.

Can bowel obstructions from adhesions be life-threatening? In severe cases, yes. A complete bowel obstruction is a medical emergency that requires immediate intervention. Symptoms of a severe obstruction may include:

• Intense abdominal pain
• Severe nausea and vomiting
• Inability to pass gas or have a bowel movement
• Abdominal distension and tenderness

It’s important to note that not all adhesion-related bowel symptoms are severe. Many women experience milder, chronic symptoms that can be mistaken for other conditions like irritable bowel syndrome (IBS).

Diagnostic Challenges: Identifying Pelvic Adhesions

Diagnosing pelvic adhesions can be a complex process, as these fibrous bands are not typically visible on standard imaging tests. This diagnostic challenge often leads to a frustrating journey for patients seeking answers to their persistent symptoms.

Limitations of Conventional Imaging

Why are pelvic adhesions difficult to detect on imaging studies? Unlike many other pelvic conditions, adhesions don’t usually show up on X-rays, ultrasounds, or even CT scans. This invisibility can lead to misdiagnosis or delayed treatment.

Diagnostic approaches for suspected pelvic adhesions may include:

1. Detailed medical history and symptom analysis
2. Physical examination, including pelvic exam
3. Imaging studies to rule out other conditions
4. Laparoscopy for direct visualization (considered the gold standard)

The Role of Laparoscopy in Diagnosis and Treatment

Laparoscopy serves a dual purpose in the management of pelvic adhesions. It allows for direct visualization of the adhesions and provides an opportunity for simultaneous treatment through adhesiolysis (surgical removal of adhesions).

How effective is laparoscopic adhesiolysis? While it can provide significant symptom relief for many patients, it’s important to note that adhesions can recur. The success rate varies depending on the extent of adhesions and the skill of the surgeon.

Prevention Strategies: Minimizing Adhesion Formation

Given the potential complications associated with pelvic adhesions, prevention is a key focus in gynecological surgery. While it’s not always possible to completely prevent adhesions, several strategies can help minimize their formation.

Surgical Techniques and Considerations

Surgical approach plays a crucial role in adhesion prevention. Minimally invasive techniques, such as laparoscopic surgery, are associated with a lower risk of adhesion formation compared to open surgeries.

Key surgical principles for adhesion prevention include:

• Minimizing tissue trauma
• Maintaining meticulous hemostasis (blood loss control)
• Avoiding unnecessary drying of tissues
• Using fine, non-reactive sutures
• Minimizing the use of cautery

Adhesion Barriers and Preventive Products

In recent years, various adhesion barrier products have been developed to reduce the risk of adhesion formation after surgery. These products create a temporary physical barrier between tissues during the critical healing period.

Types of adhesion barriers include:

1. Gel-based barriers
2. Film barriers
3. Liquid solutions
4. Solid membranes

How effective are adhesion barriers? While studies have shown promising results, their efficacy can vary. It’s important to note that no barrier product can guarantee complete prevention of adhesions.

Management Options for Existing Pelvic Adhesions

For women already experiencing symptoms of pelvic adhesions after hysterectomy, various management options are available. The choice of treatment depends on the severity of symptoms and the extent of adhesions.

Conservative Management Approaches

Non-surgical management options are often the first line of treatment for mild to moderate adhesion-related symptoms. These may include:

• Pain management techniques (medication, physical therapy)
• Pelvic floor exercises
• Lifestyle modifications
• Dietary changes to manage bowel symptoms

Surgical Interventions for Severe Cases

In cases where conservative management fails to provide adequate relief, surgical intervention may be necessary. The primary surgical approach for treating pelvic adhesions is adhesiolysis, which can be performed laparoscopically or through open surgery in more complex cases.

Are there risks associated with adhesiolysis surgery? Yes, like any surgical procedure, adhesiolysis carries risks. These may include:

• Potential for new adhesion formation
• Damage to surrounding organs
• Bleeding and infection
• Incomplete relief of symptoms

It’s crucial for patients to have a thorough discussion with their healthcare provider about the potential benefits and risks of surgical intervention for adhesions.

Long-term Outlook and Quality of Life Considerations

Living with pelvic adhesions after hysterectomy can have a significant impact on a woman’s quality of life. Understanding the long-term outlook and developing strategies for managing ongoing symptoms is essential for optimal wellbeing.

Coping with Chronic Symptoms

For many women, managing pelvic adhesions is an ongoing process. Developing effective coping strategies can help improve daily functioning and overall quality of life. These may include:

1. Regular exercise and physical therapy
2. Stress reduction techniques (e.g., meditation, yoga)
3. Joining support groups or seeking counseling
4. Working closely with healthcare providers for symptom management

Potential for Recurrence and Ongoing Care

Even after successful treatment, there’s always a potential for adhesions to recur. This underscores the importance of ongoing care and regular follow-ups with healthcare providers.

How can women minimize the risk of adhesion recurrence? While complete prevention may not be possible, the following strategies can help:

• Adhering to post-operative care instructions
• Maintaining a healthy lifestyle
• Promptly addressing any new or worsening symptoms
• Considering minimally invasive approaches for any future surgeries

By staying informed and proactive in their care, women can better navigate the challenges posed by pelvic adhesions and maintain a good quality of life post-hysterectomy.

Pelvic Adhesions

Pelvic adhesions cause many problems for millions of women. From obstructed tubes associated with infertility, to pelvic tenderness, and painful intercourse, to chronic pelvic pain. Curiously, adhesions can be very extensive, yet relatively silent. They may remain silent indefinitely, or long after the causative event, become symptomatic. The causes of adhesions are multiple but basically the tissue irritation that produces the adhesive process arises from an inflammatory event, or from trauma (i.e. post surgical).
 

Examples of an inflammatory event would be a tubal infection from a sexually transmitted disease (e.g. Gonorrhea), a post surgery infection, or appendicitis. Chronic “irritation” of the pelvic tissues from a common disease process such as endometriosis, may also incite adhesions. A very significant proportion of symptomatic pelvic adhesive disease arises from previous necessary pelvic surgery (removal of an ovarian cyst would be a good example).
 

What are “pelvic adhesions” anyway?? In the process of trying to repair injured tissue, a series of normal healing events may cause some structures in the pelvis to become unintentionally “stuck” to another tissue or structure. In a normal healthy pelvis (or the whole abdominal cavity for that matter) this large space is lined with a tissue called peritoneum, which also covers the outside of organs located in the abdomen and pelvis. In an non-injured or irritated state, the peritoneum can be likened to slippery cellophane wrap…. the organs and structures lying immediately adjacent to each other just slip off each other and do not become bonded together. Given a tissue injury, the healing process initiates a sequence of events that can result in a certain tissue becoming “stuck” to its neighbor, and when this happens certain undesirable results occur.
 

The ovary for example is a very sensitive structure, much like the testis. If as a consequence of an ovarian cystectomy, (the removal of the cyst from the ovary) the ovary becomes “attached’ to the pelvic sidewall, or the top of the vagina, the patient may experience persistent pelvic pain and/or painful intercourse. The diagnosis is suspected by a history of ovarian surgery, and subsequent persistent pain or tenderness unrelated to her menstrual cycle.
 

After a large abdominal incision (e.g. a hysterectomy for large fibroids) the bowel or an associated fatty structure called the omentum may become adherent to the abdominal wall. Adhesions begin to develop within hours of surgery. If by chance it is a loop of bowel, the patient may experience intermittent bouts of crampy pain, perhaps associated with some nausea, bloating, or even vomiting. The intestinal symptoms are related to some degree of bowel obstruction that inhibits the passage of the bowel contents or gas through the partially obstructed area. When the obstruction is severe then the patient will be very ill with nausea, distention and vomiting, and may not be passing any gas rectally. Xray studies may confirm the severe obstruction, and treatment may require decompression of the bowel by means of a tube passed through the stomach to the intestine, or even exploratory surgery.
 

More often in my experience, the symptoms are troublesome and annoying, and the obstruction is not severe enough to make any of the Xray tests informative. Often the patient will be sent to the gastroenterologist , and endoscopoic evaluation of both the upper and lower bowel will be performed . Frequently, the diagnosis is “irritable bowel syndrome”. It should be remembered that intra-abdominal and pelvic adhesions rarely if ever show up on Xray or ultrasound. Unfortunately, every time an abdominal incision is performed, the risk is present for recurrent adhesion problems. The good news is however that most patients will not develop serious post-operative adhesions causing further problems. Those unfortunate to do so may ultimately undergo repeated surgeries, always hoping that “this will do it!!”
 

Does everybody develop adhesions?? No they do not, but it is not understood why one person develops very extensive adhesions, and the next individual none at all. The nature of the traumatic tissue event, the duration of the inflammatory insult, the nature of the preceding surgery, the operative technique of the surgeon, and the unknown healing characteristics of a given individual all interplay in the final outcome.
 

What can be done to minimize pelvic adhesions from forming? Early treatment of an infectious process if identified, utilization of safe sex practices to minimize the transmission of sexually transmitted disease, meticulous surgical technique to minimize unnecessary tissue trauma, and perhaps using barrier products where appropriate. The latter may be helpful in reducing the extent or severity of the post operative adhesion development.
 

What to do if symptomatic adhesions develop, what are the patients options? The first option in any situation is don’t do anything. Pain is a relative experience, and the degree of severity will vary from individual to individual. Minor, or even moderately severe discomfort can often be lived with, or controlled by medication, acupuncture, or medical hypnosis. Not infrequently pelvic pain is not helped by conventional treatment such as hormones, pain medicine, or even surgery. In those circumstances, non-conventional treatment with acupuncture or hypnosis can sometimes be very helpful.
 

Given significant symptomatic pelvic adhesions being suspected from the history and physical exam, a thorough workup is indicated , which may include special xray studies and ultrasound. Ultimately, laparoscopy may be utilized to allow visual inspection of the intra-abdominal organs. What to do surgically depends on the findings. If an ovary is bound down with adhesions from previous surgery, the extent of the adhesive process may indicate a simple cutting of the adhesions or if necessary, removal of the ovary. If the patient has completed her fertility requirements, and if the pelvic adhesive process is very extensive, a complete hysterectomy with removal of both tubes and ovaries may be indicated. Obviously, the patient and her gynecologist need to have had a very comprehensive and detailed discussion about what might be encountered, and what options might be exercised.
 

What about abdominal wall adhesions resulting from prior abdominal surgery? These can usually be taken down laparoscopically, thus minimizing tissue injury, as opposed to a conventional large incision. Multiple tiny incisions may be necessary in order for the surgeon to see well, and from different angles the area of dense adhesions. Nonetheless, several tiny 1/2 inch incisions are far less uncomfortable than a conventional laparotomy incision.
 

If the adhesions are extensive, and the patient has undergone previous adhesion surgery that failed, I have taken an unorthodox approach to such individuals. Because adhesions begin to form almost immediately, along with the healing process involving the raw anterior abdominal wall, I have in special situations recommended a repeat laparoscopy in one week. At this point, the “new” adhesions are flimsy, soft, do not contain a blood supply, and can be swept away with minimal tissue injury, compared to a conventional adhesiolysis (freeing the adhesions surgically) of old adhesions that are dense, very adherent, and bloody. This is performed in an outpatient setting, and usually takes but a few minutes, compared to the time involved dealing with extensive, dense old adhesions.
 

It is important that patients inquire about their surgeon’s experience with extensive adhesions, because what might be viewed as “not possible laparoscopically” by one gynecologist, may be very familiar territory for another. Because bowel may be intimately involved with the adhesive process the patient has to be aware that the worst case scenario may require bowel surgery, and a conventional laparotomy incision.
 

Pelvic adhesions can be a serious detrimental quality of life issue. Some patients are total pelvic cripples because of this problem. Once formed, they do not disappear with time. If you are suffering from some of the medical complaints outlined earlier, do consider a consultation with an experienced laparoscopic gynecologist and hopefully your adhesive problems can be solved.

Adhesions, General and After Surgery

Adhesions Overview

An adhesion is a band of scar tissue that binds two parts of your tissue that are not normally joined together. Adhesions may appear as thin sheets of tissue similar to plastic wrap or as thick fibrous bands.

The adhesion develops when the body’s repair mechanisms respond to any tissue disturbance, such as surgery, infection, trauma, or radiation, resulting in inflammation. Although adhesions can occur anywhere, the most common locations are within the abdominal cavity, the pelvis, and the heart.

• 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 about 10% of people who have never had surgery.
  • Most adhesions are painless and do not cause complications. However, adhesions cause about 60% of small bowel obstructions in adults and are believed to contribute to the development of chronic pelvic pain.
  • 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.
• 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. 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 their fallopian tubes into their uterus for reproduction. Fallopian adhesions can lead to infertility and increased incidence of ectopic pregnancy in which a fetus develops outside the uterus. Endometriosis, a condition in which tissue normally found inside the uterus grows in other parts of the body such as the bowel or fallopian tubes, may also be caused by pelvic adhesions.
• Pleural adhesions: Adhesions may form around the lungs after pneumonia, tuberculosis, or surgery.
• Heart adhesions: Scar tissue may form within the membranes that surround the heart (pericardial sac), thus restricting heart function. Infections, such as rheumatic fever, may lead to adhesions forming on heart valves and can lead to decreased heart efficiency.

Adhesions Causes

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 two surfaces.

Adhesions Symptoms

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.

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

• Adhesions above the liver may cause pain with deep breathing.
• Intestinal adhesions may cause pain due to obstruction or pain from tugging during exercise or when stretching.
• Adhesions involving the vagina or uterus may cause pain during intercourse.
• Adhesions around the lungs may cause shortness of breath. 
• Pericardial adhesions may cause chest pain or difficulty breathing.
• It is important to note that not all pain is caused by adhesions and not all adhesions cause pain.
• Small or large bowel obstruction (intestinal blockage) due to adhesions is a surgical emergency.
  • These adhesions may 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 abdomen 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 sometimes 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 becomes distended.
  • Fever may increase.
  • Further progression can tear your intestinal wall and contaminate your abdominal cavity with bowel contents.

When to Seek Medical Care

See a doctor any time you experience abdominal pain, pelvic pain, or unexplained fever. If you have undergone surgery or have a history of medical illness, discuss any changes in your recovery or condition with your doctor.

Call 911 and go to the nearest emergency department if chest pain occurs.

Exams and Tests

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.

Adhesions Treatment – Self-Care at Home

Adhesions must be diagnosed and treated by a physician.

Medical Treatment

Treatment varies depending on the location, extent of adhesion formation, and problems the adhesion is causing. Adhesions frequently improve without surgery. Therefore, unless a surgical emergency becomes evident, a doctor may treat symptoms rather than perform surgery.

Surgery

Two common surgical techniques used to treat abdominal adhesions are laparoscopy and laparotomy.

• With laparoscopy, a doctor places a camera into your body through a small hole in the skin to confirm that adhesions exist. The adhesions then are cut and released (adhesiolysis).

• In laparotomy, a doctor makes a larger incision to directly see adhesions and treat them. The technique varies depending on specific circumstances.

Next Steps – Follow-up

If you have undergone surgery or have a history of medical illness, always discuss changes in your recovery or condition with your doctor.

Prevention

Steps are taken during surgery to try and minimize the formation of adhesions. Some of these may include: shortening surgical time, keeping the tissues moist, gentle handling of any tissues or organs, and using starch –free and latex-free gloves. Several surgical products have also been developed to try to help prevent adhesions from forming during surgery. Film-like sheets are sometimes used between organs or body surfaces after large, open surgical procedures.

Outlook

Adhesions requiring surgery commonly come back because surgery itself causes adhesions.

Synonyms and Keywords

adhesion, pelvic adhesion, heart adhesion, pericardial adhesion, intrauterine adhesion, tissue disturbance, surgery, infection, trauma, radiation, scar tissue, small-bowel obstruction, pelvic pain, chronic pelvic pain, intestinal adhesion, general adhesion, general adhesions, adhesion after surgery, adhesions after surgery, abdominal adhesion, adhesion causes, adhesion symptoms

Adhesions and How They Are Treated at Seckin Endometriosis Center

September 20, 2019 | by drseckin.com.

Cancer, Fibroid, Polyp, and Adhesions

Endometriosis is the most common cause of adhesions in the pelvic and abdominal cavity. Years ago, researchers thought that the most common cause of adhesions was pelvic inflammatory disease (PID).

Endometriosis adhesions cause scarring and fibrous bands to form, which contain endometriosis glands, stroma, and inflammation. This is in contrast to more typical adhesions caused by repeated surgery, which contain only fibrous bands.

The most common endometriosis adhesions form and cause scarring within the ovaries, fallopian tubes, uterus, small intestines, and pelvic sidewall, between the bowel, rectum, and recto-vaginal septum. These “sticky” adhesions can cause the space between two organs to fill with scar tissue and inflammatory enzymes. This ultimately can lead to pain in the pelvis and abdomen. So, it is important to clearly define them, state their role in endometriosis development, and discuss treatment options for patients in their day-to-day life.

Endometriosis adhesion formation can commonly cause the normal posterior cul-de-sac (tissue space between the uterine wall and rectum) to disappear, as the posterior uterine wall and anterior rectum, and sigmoid colon are fused together via a thick fibrous band of tissue.

How do they form?

Most adhesions form in response to a tissue disturbance that triggers the body’s repair mechanism. There are a variety of factors that can trigger this including surgery, infections, and diseases such as endometriosis.

Superficial-surface adhesion causing a fibrous band to span within the pelvic cavity.

Adhesions secondary to surgery

One of the most common causes of adhesions is surgery. This occurs as a result of the body’s natural attempt to maintain homeostasis (balance).

Following a C-section, it is common for adhesions to form in the bladder with a band-like tightness that spans to the anterior wall of the uterus. This can cause difficulty or pain with urination.

Adhesions can also form along the anterior and posterior uterine wall following myomectomy, even upon laparoscopic procedures. In fact, bleeding can often arise upon posterior myomectomy procedures. Therefore, it is crucial that you find a surgeon who will actively work to minimize bleeding through meticulous skill and experience. This will ensure a reduced risk for further adhesion formation and loss of blood.

Even when surgeons remove the uterus with hysterectomy, adhesions can form on the surrounding reproductive and pelvic organs. These include the ovaries, bowels, and bladder.

Surgery should only be performed as a last resort and if other treatment options are not beneficial to the patient.

The point of conducting surgery is to help the patient and relieve their symptoms. However, this does not mean that complications cannot arise and that there are no risks. Therefore, it is important to discuss with your doctor whether surgery is the right choice for you. If so, speak with your surgeon about the ways they ensure minimal risk and a minimally invasive surgical approach.

Adhesions secondary to infection

Infectious diseases can often lead to adhesions. This includes infection that causes PID and can be cause for concern, as they can increase a woman’s risk of infertility and ectopic pregnancy.

Adhesions secondary to innate pathology (i.e. endometriosis)

When we say adhesions caused by pathology, we mean those forming due to a much more serious disease. Endometriosis is just one example. Endometriosis adhesions, composed of ectopic endometrial tissue, inflammatory enzyme, and old, pooled menstrual blood, can form throughout the pelvic cavity. These can be a cause for concern as their formation can increase a patient’s chances of experiencing the symptoms of the underlying disease as well as putting them at a higher risk of infertility, bowel dysfunction, or obstruction.

Adhesions secondary to endometriosis encasing the ureter, which is common to find following c-section surgery.

Symptoms

Pelvic adhesions can cause varying symptoms. This depends on their severity and location. The most common universal symptom that adhesions can cause is pain due to pulling on nerves. This occurs as the adhesions glue organs together due to their “sticky” nature. This causes overlapping and pressure on specific nerves and tissue within the area. Other symptoms include:

• pain with deep breathing
• painful bowel movements, cramps, constipation, diarrhea, gas, bloatedness, nausea, vomiting, decreased appetite, weight loss, difficulty passing stool
• pain with intercourse or menstruation

However, physicians usually attribute these symptoms to the diseases that adhesions cause, rather than the adhesions themselves, leading to misdiagnosis or inefficient treatment.

If you are experiencing any of these symptoms, and feel that pelvic adhesions are a probable cause of your pain, you should alert your gynecologist immediately. However, remember that not all adhesions cause pain and not all pain is due to adhesions

Endometriosis adhesions in the pelvic and lower abdominal cavity can sometimes infiltrate vital organs such as the ureter and uterine artery. Patients can experience symptoms such as neuropathy (pain due to nerve damage) and bowel dysfunction.

Endometriosis adhesions

Endometriosis adhesions are unique and different from any other form of adhesions. They are often described as a sort of super glue. This is because they possess a certain “sticky” component that makes them fuse other tissues together and connect organs. This eliminates the dissection line during surgery. Normally, this space clearly separates adjacent organs. However, in the case of endometriosis, it is remarkably difficult to distinguish the line of tissue that should separate said organs. The loss of normal surgical planes can change the contour of an organ making surgery very difficult.

Endometriosis adhesions are “alive”. This means that they contain glands and stroma with endometriosis tissue within the adhesions that are reactive to estrogen. These can resemble the leakage of endometriosis material from a chocolate cyst (endometrioma). The melted chocolate-like material, which is a combination of pooled menstrual blood, inflammatory enzymes, and endometriosis tissues produced from an endometrioma fuses organs together by forming a layer of “sticky” glue-like tissue. Thus the endometriosis tissue contained within this material may be responsible for progressing into more advanced and severe adhesions that fuse organs together in extreme cases.

When organs are fused they cannot function well. This leads to issues such as rectal constriction causing constipation or retroperitoneal infiltration, leading to retroperitoneal fibrosis. It can also cause severe sharp pain with intercourse or an inability to tolerate it with a deep pulling sensation. Other inner anatomical abnormalities that can arise from adhesions include ureter and bowel blockages and deep cul-de-sac scarring and obliteration. In this sense, endometriosis adhesions are unique in comparison with the adhesions that form due to surgery.

Mechanism of Adhesions

What are the steps of progression?

During early endometriosis, the primary organ affected is the peritoneum (the lining of the abdomen). However, the exact cause leading to the progression of stage 1 endometriosis and further development is not clear. While there are several theories, ranging from Sampson’s theory of retrograde menstruation to the stem cell theory of endometriosis, it is likely that there may not be one singular cause. Instead, a multitude of mechanisms likely work alongside one another. Either way, small patches and lesions of endometriosis tissue within the peritoneum are a common anomaly in cases of early endometriosis development.

In more severe cases of endometriosis, it is not uncommon to find endometriosis tissue on the ovaries. This collection of endometriosis can cause the formation of an ovarian cyst called an endometrioma. This also consists of pooled menstrual blood and inflammatory enzymes. This “chocolate cyst,” termed after the brown serous fluid it consists of, is then susceptible to leakage during menstruation and subsequent further spreading of endometriosis within the pelvic cavity. This material can then go on and form adhesions throughout the pelvic cavity.

When the leakage of this material spreads throughout the pelvic cavity, endometriosis adhesions grow and spread. These adhesions serve as a “glue” that holds inflamed pelvic organs in place. They can ultimately result in extreme cases like frozen pelvis. This can cause symptoms such as chronic pelvic pain, killer cramps, and pain with sexual intercourse.

Where do endometriosis adhesions commonly form?

Most commonly, endometriosis adhesions adhere to the pelvic cavity due to their uterine origin. Below are a few common organ within the pelvic cavity where endometriosis adhesions adhere to:

Adhesions formed secondary to endometriosis (outside of the uterus, ovaries, and fallopian tubes).

• uterine muscle layer or serosa layer (adenomyosis)
• fallopian tubes
• ovaries (endometrioma)
• bladder
• ureter
• cul-de-sac (both posterior and anterior)

A fibrous band of adhesion tissue spanning from the ovary to the uterine wall.

Adhesions also commonly affects organs within the abdominal cavity, particularly in cases of bowel endometriosis, which is seen in nearly one in every five endometriosis patients.

Common sites within the abdominal cavity that endometriosis adhesions stick to include:

• peritoneum
• rectum
• colon (large intestine)
• appendix
• ileum (final section of small intestine)

In rare instances, endometriosis implants and adhesions can incorporate a variety of other locations, which include:

• cervix (excluding endometrial layer)
• vagina
• nerves
• lungs
• brain

How can endometriosis lead to retroperitoneal fibrosis?

Retroperitoneal fibrosis is when fibrous adhesions form in the space behind the peritoneum. This can often be due to endometriosis adhesions infiltrating the peritoneum and spreading through the wall.

When this occurs, the adhesions can continue to spread and are often associated with the involvement of the ureter and deep nerves. This will cause symptoms such as neuropathy (pain due to nerve damage), particularly in the legs and below the lower abdomen. In these cases, it is important that these adhesions are meticulously removed through “cold” excision surgery, using minimal to no electrical energy. In this way, the pelvic and abdominal cavity is repaired/restored and reconstructed.

Diagnosis

Adhesions are not a formal medical diagnosis. However, we strongly recommend that you see a doctor if you experience these symptoms.

The underlying pathology cannot be identified with any simple form of a diagnostic exam. In order to do so, a surgeon must take a biopsy sample during laparoscopic surgery. He or she then sends this specimen to a pathology lab, where a pathologist will observe it under a microscope and provide a report with an official diagnosis.

Treatment

Doctors must diagnose and treat adhesions medically. Treatment can vary depending on the severity and location of the adhesions, as well as the bigger issue that the adhesion is causing.

Non-surgical treatment

Because many adhesions do not cause any symptoms at all, surgery does not become necessary unless in case of an emergency. In fact, they often improve without surgery. Even in instances of mild pain, a physician will more commonly treat the symptoms than go to such extensive measures as surgery.

Diet

Diet certainly cannot rid a patient of their pelvic and abdominal adhesions. However, it can help play a role in symptom relief. Because abdominal adhesions can implant on the bowels, they often mask themselves as other disorders like irritable bowel syndrome (IBS). These can include nausea, constipation, small bowel production, and bowel obstruction. So, it can be helpful to adopt lifestyle and dietary changes, such as the FODMAP diet that can help relieve such symptoms.

Surgical treatment

The two most common forms of surgically treating pelvic and abdominal adhesions are laparoscopy and laparotomy. These differ primarily in terms of invasiveness.

The gold standard for removing endometriosis adhesions is through deep-excision surgery, with minimal electricity or heat used.

Laparoscopy is minimally invasive surgical technique in which a doctor makes several small incisions into the abdomen, which they inflate with gas. They then insert a small camera or laparoscope through one of these small incisions to visualize the abdomen and pelvic cavity and confirm the presence of adhesions. They then insert other tools through the two or three other incisions to cut the adhesions, a process known as adhesiolysis.

A laparotomy is an open surgical technique where the surgeon makes a large incision from the navel (belly button) down to the abdomen. This gives them full access and visualization of the abdominal and pelvic organs. Laparotomy is a much more invasive technique and thus presents more risk of a difficult recovery. Therefore, in most cases, laparoscopy is the preferred form of surgery. However, only an experienced and skilled surgeon can perform this. It is important to remember that surgery in itself can cause adhesions. However, there are few proven methods to prevent this.

Our approach

Following the excision of adhesions, a surgeon must be able to repair, reconstruct, and restore normal anatomical function. This is the bowel reconstructed after adhesiolysis.

At Seckin Endometriosis Center, we are committed to performing laparoscopic surgery. We believe that a patient’s best chance of a healthy recovery and symptom relief is through minimally invasive surgery. Thus, we perform excision surgery to remove all suspected adhesions as an initial step in surgery. Additionally, we are able to better view and thus remove endometriosis adhesions through our patented ABC technique. Our method differs from traditional adhesiolysis. We firmly believe that both endometriosis adhesions and their surrounding scar tissue must be meticulously removed through excision. This ensures that adhesions are fully removed individually, including the underlying tissue beneath the surface. After decades of training and experience and with a team approach, we are able to provide a highly thorough and productive surgery, which includes repairing, reconstructing, and restoring the organs that were operated on.

Superficial surface adhesions within the pelvic cavity, pre-and post-injection of our patented ABC contrast. The contrast makes the endometriosis scar tissue and inflammation from the adhesion much more visible and thus easier to remove.

If you or your doctor feel that you could have pelvic adhesions and have had constantly recurring pain, please feel free to call us to discuss your case.

Pelvic adhesions due to endometriosis can be a very grueling condition to endure, and even more so to treat. We have worked tirelessly to improve upon our techniques to ensure that our patients receive the conservative and definitive surgery that they both need and deserve.

Abdominal Adhesions | NIDDK

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What are abdominal adhesions?

Abdominal adhesions are bands of scar-like tissue that form inside your abdomen. The bands form between two or more organs or between organs and the abdominal wall.

Normally, the surfaces of organs and your abdominal wall do not stick together when you move. However, abdominal adhesions may cause these surfaces to become adherent, or stick together.

Abdominal adhesions can kink, twist, pull, or compress the intestines and other organs in the abdomen, causing symptoms and complications, such as intestinal obstruction or blockage.

How common are abdominal adhesions?

Abdominal adhesions are common and often develop after abdominal surgery. In abdominal surgery, surgeons enter a patient’s abdomen through an incision, or cut. Abdominal surgery may be laparoscopic or open.

In laparoscopic surgery, which is increasingly common, surgeons make small cuts in the abdomen and insert special tools to view, remove, or repair organs and tissues. In open surgery, surgeons make a larger cut to open the abdomen.

Abdominal adhesions develop in more than 9 out of every 10 people who have surgery that opens the abdomen.^1,2,3 However, a majority of people with abdominal adhesions do not develop symptoms or complications.¹ Abdominal adhesions are less common after laparoscopic surgery than after open surgery.³

Who is more likely to have abdominal adhesions?

People who have had abdominal surgery are more likely to have abdominal adhesions. Among people who have had abdominal surgery, adhesions and related complications are more common in people who⁴

What are the complications of abdominal adhesions?

Abdominal adhesions can cause intestinal obstruction and female infertility.

Intestinal obstruction

Intestinal obstruction is the partial or complete blockage of the movement of food, fluids, air, or stool through the intestines. Abdominal adhesions are the most common cause of obstruction of the small intestine.⁵ Intestinal obstruction may lead to

• lack of blood flow to the blocked part of the intestine and death of the blood-starved intestinal tissues
• peritonitis, an infection of the lining of the abdominal cavity

Intestinal obstruction can be life-threatening. People with symptoms of a complete blockage—which include abdominal pain and passing no fluids, stool, or gas—should seek medical attention right away.

Female infertility

In women, abdominal adhesions in the pelvis or inside the uterus can compress or block parts of the reproductive system and cause infertility.

What are the symptoms of abdominal adhesions?

In many cases, abdominal adhesions do not cause symptoms. If they do cause symptoms, chronic abdominal pain is the most common symptom.

Abdominal adhesions may cause intestinal obstruction, which can be life-threatening. If you have symptoms of intestinal obstruction, seek medical help right away.

Symptoms of intestinal obstruction may include

If intestinal obstruction cuts off the blood flow to the blocked part of the intestines or leads to peritonitis, you may develop additional symptoms such a fast heart rate or fever.

What causes abdominal adhesions?

Abdominal surgery is the most common cause of abdominal adhesions. Adhesions caused by surgery are more likely to cause symptoms and complications than adhesions related to other causes. Symptoms and complications may start any time after surgery, even many years later.³

Conditions that involve inflammation or infection in the abdomen may also cause adhesions. These conditions include Crohn’s disease, diverticular disease, endometriosis, pelvic inflammatory disease, and peritonitis.

Other causes of abdominal adhesions include long-term peritoneal dialysis to treat kidney failure and radiation therapy to treat cancer.

In some cases, abdominal adhesions are present at birth.

Abdominal surgery is the most common cause of abdominal adhesions.

How do doctors diagnose abdominal adhesions?

Doctors use medical history, physical exam, blood tests, imaging tests, and, in some cases, surgery to diagnose abdominal adhesions.

Medical history

A doctor will ask about your symptoms and your medical history, including your history of abdominal surgery or other conditions that may cause abdominal adhesions. A doctor will also ask about your history of other diseases and disorders that may cause symptoms similar to those of abdominal adhesions.

Physical exam

During a physical exam, the doctor may tap on your abdomen to check for tenderness or pain and use a stethoscope to listen to sounds in your abdomen.

Blood tests

A health care professional will take blood samples and send the samples to a lab. Although blood tests can’t be used to diagnose abdominal adhesions, doctors may order blood tests to rule out other health problems that could be causing your symptoms. If you have signs of an intestinal obstruction, blood tests can help doctors find out how severe the obstruction is.

Imaging tests

Imaging tests most often cannot show abdominal adhesions. However, doctors can use imaging tests to diagnose intestinal obstruction caused by abdominal adhesions. Doctors may also use imaging tests to rule out other problems that may be causing your symptoms.

Imaging tests may include

• computerized tomography (CT), which uses a combination of x-rays and computer technology to create images. A CT scan may help doctors diagnose intestinal obstruction and find the location, cause, and severity of the obstruction.
• x-rays, which use a small amount of radiation to create pictures of the inside of the body.
• x-rays with water-soluble contrast medium, a special liquid that makes the digestive tract more visible on x-rays. If adhesions are causing an intestinal obstruction, this imaging test can help doctors find out if you need surgery. The water-soluble contrast medium may also help relieve the obstruction.
• lower GI series, which uses x-rays to view your large intestine.

Doctors can use imaging tests to diagnose intestinal obstruction caused by abdominal adhesions or rule out other problems.

Surgery

In some cases, doctors may recommend surgery to look inside the abdomen and check for adhesions or other problems that may be causing symptoms. Surgeons may check for abdominal adhesions with laparoscopic or open surgery.

In some cases, surgeons may be able to treat the problem during the procedure.

How do doctors treat abdominal adhesions?

If abdominal adhesions don’t cause symptoms or complications, they typically don’t need treatment.

If abdominal adhesions cause symptoms or complications, doctors can release the adhesions with laparoscopic or open surgery. However, surgery to treat adhesions may cause new adhesions to form. If you have abdominal adhesions, talk with your doctor about the possible benefits and risks of surgery.

If abdominal adhesions cause an intestinal obstruction, you will need treatment at a hospital right away. Doctors will examine you and may order tests to find out if you need emergency surgery. If you do, surgeons will release the adhesions, relieving the intestinal obstruction.

If you don’t need emergency surgery, doctors may try to treat the obstruction without surgery. Health care professionals will give you intravenous (IV) fluids and insert a tube through your nose and into your stomach to remove the contents of your digestive tract above the obstruction. In some cases, the obstruction may go away. If the obstruction does not go away, surgeons will perform surgery to release the adhesions, relieving the intestinal obstruction.

Can abdominal adhesions be prevented?

When performing abdominal surgery, surgeons take steps to lower the chance that patients will develop abdominal adhesions and related complications after surgery. For example, surgeons may

• recommend laparoscopic surgery, if possible, instead of open surgery.
• handle tissues gently to prevent damage.
• take steps to keep foreign materials out of the abdomen, such as using powder-free gloves and lint-free tools.
• cover damaged tissues inside the abdomen with a special film-like barrier at the end of surgery. The barrier keeps tissues separated while they heal, and then the barrier is absorbed by the body.

Clinical Trials for Abdominal Adhesions

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions, including digestive disorders.

What are clinical trials for abdominal adhesions?

Clinical trials—and other types of clinical studies—are part of medical research and involve people like you. When you volunteer to take part in a clinical study, you help doctors and researchers learn more about disease and improve health care for people in the future.

Researchers are studying many aspects of abdominal adhesions, such as improving diagnosis and treatment of adhesions.

Find out if clinical studies are right for you.

What clinical studies for abdominal adhesions are looking for participants?

You can find clinical studies on abdominal adhesions at www.ClinicalTrials.gov. In addition to searching for federally funded studies, you can expand or narrow your search to include clinical studies from industry, universities, and individuals; however, the NIH does not review these studies and cannot ensure they are safe. Always talk with your health care provider before you participate in a clinical study.

References

[1] Tabibian N, Swehli E, Boyd A, Umbreen A, Tabibian JH. Abdominal adhesions: a practical review of an often overlooked entity. Annals of Medicine and Surgery. 2017;15:9–13.

[2] Okabayashi K, Ashrafian H, Zacharakis E, et al. Adhesions after abdominal surgery: a systematic review of the incidence, distribution, and severity. Surgery Today. 2014;44:405–420.

[3] Beyene RT, Kavalukas SL, Barbul A. Intra-abdominal adhesions: anatomy, physiology, pathophysiology, and treatment. Current Problems in Surgery. 2015;52(7):271–319.

[4] Moris D, Chakedis J, Rahnemai-Azar AA, et al. Postoperative abdominal adhesions: clinical significance and advances in prevention and management. Journal of Gastrointestinal Surgery. 2017;21(10):1713–1722.

[5] Di Saverio S, Coccolini F, Galati M, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World Journal of Emergency Surgery. 2013;8(1):42.

Abdominal Adhesions – IFFGD

Description and Causes

What are abdominal adhesions?

Abdominal adhesions are bands of tissue that form between abdominal tissues and organs. Normally, internal tissues and organs have slippery surfaces, which allow them to shift easily as the body moves. Adhesions cause tissues and organs to stick together.

The intestines are part of the digestive system. Abdominal adhesions can cause an intestinal obstruction.

Although most adhesions cause no symptoms or problems, others cause chronic abdominal or pelvic pain. Adhesions are also a major cause of intestinal obstruction and female infertility.

What causes abdominal adhesions?

Abdominal surgery is the most frequent cause of abdominal adhesions. Almost everyone who undergoes abdominal surgery develops adhesions; however, the risk is greater after operations on the lower abdomen and pelvis, including bowel and gynecological surgeries. Adhesions can become larger and tighter as time passes, causing problems years after surgery.

Surgery-induced causes of abdominal adhesions include:

• tissue incisions, especially those involving internal organs
• handling of internal organs
• the drying out of internal organs and tissues
• contact of internal tissues with foreign materials, such as gauze, surgical gloves, and stitches
• blood or blood clots that were not rinsed out during surgery

A less common cause of abdominal adhesions is inflammation from sources not related to surgery, including:

• appendicitis—in particular, appendix rupture
• radiation treatment for cancer
• gynecological infections
• abdominal infections

Rarely, abdominal adhesions form without apparent cause.

How can abdominal adhesions cause intestinal obstruction?

Abdominal adhesions can kink, twist, or pull the intestines out of place, causing an intestinal obstruction. An intestinal obstruction partially or completely restricts the movement of food or stool through the intestines.

Intestinal obstruction requires immediate medical attention.

How can abdominal adhesions cause female infertility?

Abdominal adhesions cause female infertility by preventing fertilized eggs from reaching the uterus, where fetal development takes place. Adhesions can kink, twist, or pull out of place the fallopian tubes, which carry eggs from the ovaries—where eggs are stored and released—to the uterus.

Symptoms and Diagnosis

What are the symptoms of intestinal obstruction?

Intestinal obstruction can be partial or complete. A complete intestinal obstruction is life threatening.

Symptoms of an intestinal obstruction include:

• Severe abdominal pain or cramping
• Vomiting
• Bloating
• Loud bowel sounds
• Swelling of the abdomen
• Inability to pass gas
• Constipation

A person with these symptoms should seek medical attention immediately.

What are the symptoms of abdominal adhesions?

Although most abdominal adhesions go unnoticed, the most common symptom is chronic abdominal or pelvic pain. The pain often mimics that of other conditions, including appendicitis, endometriosis, and diverticulitis.

How are abdominal adhesions and intestinal obstructions diagnosed?

No tests are available to diagnose adhesions, and adhesions cannot be seen through imaging techniques such as x-rays or ultrasound. Most adhesions are found during exploratory surgery.

An intestinal obstruction, however, can be seen through abdominal x-rays, barium contrast studies (also called a lower GI series), and computerized tomography.

Treatment and Prevention

How are abdominal adhesions and intestinal obstructions treated?

Treatment for abdominal adhesions is usually not necessary, as most do not cause problems. Surgery is currently the only way to break adhesions that cause pain, intestinal obstruction, or fertility problems.

More surgery, however, carries the risk of additional adhesions and is avoided when possible.

A complete intestinal obstruction usually requires immediate surgery. A partial obstruction can sometimes be relieved with a liquid or low-residue diet.

A low-residue diet is high in dairy products, low in fiber, and more easily broken down into smaller particles by the digestive system.

Can abdominal adhesions be prevented?

Abdominal adhesions are difficult to prevent; however, surgical technique can minimize adhesions.

Laparoscopic surgery avoids opening up the abdomen with a large incision. Instead, the abdomen is inflated with gas while special surgical tools and a video camera are threaded through a few, small abdominal incisions. Inflating the abdomen gives the surgeon room to operate.

If a large abdominal incision is required, a special film-like material (Seprafilm) can be inserted between organs or between the organs and the abdominal incision at the end of surgery. The film-like material, which looks similar to wax paper, is absorbed by the body in about a week.

Other steps during surgery to reduce adhesion formation include using starch and latex-free gloves, handling tissues and organs gently, shortening surgery time, and not allowing tissues to dry out.

Source
Adapted from “Abdominal Adhesions”– IFFGD Publication #249. From NIH Publication No. 13-5037, September 2013.
The text of this article is not copyrighted.

Gynecologic Surgeries for Pain | GLOWM

INTRODUCTION

Pain is the clinical indication for 40% of laparoscopies¹ and approximately 12% of hysterectomies.² Although pain has been attributed to virtually all forms of pelvic reproductive pathology, there is no gynecologic pathologic entity that causes pain in everyone who has it. The decision to operate therefore represents delicate clinical judgment in many instances. Because evaluation methods are subjective and imprecise, outcomes are variable.

The purpose of this chapter is to review procedures commonly done for pelvic pain from the perspectives of diagnosis, surgical procedure, and outcome. I discuss newer techniques such as pain mapping for evaluating the somatic and visceral contributions to pain. However, the discussion assumes that complete clinical assessment of contributions from other organ systems and evaluation of psychosocial factors has already taken place. This chapter reviews treatment of postoperative adhesions, retained ovaries, ovarian remnants, vaginal apex revision, presacral neurectomy, and uterovesical ganglion excision.

As described elsewhere in greater detail,^3,4 most problems of pelvic pain are diagnosed on the basis of a careful history. Attention to the details of the pain complaint, including a careful chronologic review of the accrual of new aspects of the pain, changes in its intensity, and the time course of the pain over the day and work week, often yield a relatively short list of diagnostic possibilities.

In terms of examination technique, a few general points are worth making. When evaluating a pelvic pain problem, the examiner should be willing to think flexibly about the sequence of the components of the examination. For example, routine insertion of the speculum before digital palpation sometimes serves only to evoke substantial discomfort, making the patient more reactive to subsequent digital examination and confusing the diagnostic interpretation. For example, if the history suggests that levator spasm may be present, I often palpitate the pelvic floor musculature before speculum insertion. It is wise to examine the areas in which you anticipate less pain before moving on to more sensitive areas. The accuracy of pain reports can be improved by encouraging the patient to focus on what she is experiencing at a given moment, rather than allowing her to look ahead with anxious anticipation to what will be painful in future parts of the examination.

It is often difficult to distinguish internal visceral or reproductive organ components of pain from more somatic or myofascial components emerging from the pelvic floor or the abdominal wall. To try to distinguish these sources, separately employ the vaginal and abdominal hand components of the examination before merging them in the standard bimanual approach. Transvaginal palpation of the uterus, broad ligaments, and adnexal areas can be accomplished without the addition of the abdominal hand for the purpose of identifying a general area from which pain signals emerge. The vaginal hand can then retreat, allowing a repeat examination of these same areas with the abdominal hand only. The examiner should ask which technique evokes discomfort most closely resembling the pain that she usually experiences. The two examining hands can then be joined in the standard bimanual examination and the diagnostic impression formed. When this technique fails to adequately clarify the diagnosis, conscious pain mapping using microlaparoscopic techniques under conscious sedation can be helpful.⁵

HYSTERECTOMY

Performing hysterectomy for the treatment of chronic pelvic pain has always been a controversial subject. The uncertainties surrounding this procedure stem from several sources. Most cautionary reports are derived from referral center practices in academic medical centers.^6,7,8 Patients following this care path are more likely to have complications in terms of overlapping physical, multisystem, and psychosocial elements. Reports from these populations report usually “failure” rates of 25% to 50% for hysterectomy for chronic pelvic pain. In contrast, reports derived from nonreferred primary care practices are more optimistic.^9,10 In these studies, when reevaluated at 1 year after surgery, more than 90% of women who had hysterectomy for pelvic pain were satisfied. It appears that the primary care gynecologists in that study made accurate judgments concerning the general indications for hysterectomy. In contrast, academic centers derive a greater proportion of their practice volume from women referred because of the chronicity of their pain and medical or psychosocial complexity. Success rates would be expected to be lower for this group.

The traditional psychoanalytic interpretation of some pain complaints may be another factor that colors the approach to hysterectomy for chronic pelvic pain. If evaluation does not reveal concrete pathology with an obvious relationship to pain, the analytic interpretation may suggest that the pain is an outgrowth of internal conflict and hence is likely to reside in a different organ system after the hysterectomy has been performed. This phenomenon has been called symptom substitution. Many valid clinical examples of this phenomenon exist, but in the Maine Women’s Health Study,⁹ only 8% of women undergoing hysterectomy for pelvic pain had experienced new unexplained symptoms during the subsequent year. Given the very high proportion of complaints seen in the general primary care office that are functional or stress related, this would seem to be a very reasonable figure.

One weakness of the Maine Women’s Health Study is that the type and degree of pathology seen in patients undergoing hysterectomy for pain was not well documented. However, examination of pathologic or histologic findings have never been very informative in explaining the intensity of pelvic pain. The most common forms of pathology associated with pelvic pain, such as adhesions, endometriosis, pelvic congestion, adenomyosis, or alteration of pelvic support or uterine positioning, do not lend themselves to ready pathologic quantitation.

A further weakness in the general literature on hysterectomy for pelvic pain is the absence of structured assessment of the contributions of other organ systems to pelvic complaints. In women undergoing hysterectomy in which no pathology is found, a higher than expected proportion qualify for the diagnosis of irritable bowel syndrome.¹⁰ By the same token, much emphasis is being placed on the muscular components of pelvic pain, especially pelvic floor levator spasm.¹¹ In the “failures” seen in previous reports of hysterectomy, it is impossible to tell the degree to which these other components were evaluated.

Ovarian function can be completely suppressed with GnRH agonist medications. This would seem to eliminate reproductive tract function from the clinical environment and thereby provide a way to evaluate the contribution of the reproductive organs to the pain syndrome. However, gonadotropin-releasing hormone (GnRH) agonists may also alter gastrointestinal motility¹² and have even been investigated as possible therapeutic agents for severe irritable bowel syndrome. I have had clinical experience supporting this notion and therefore remain unconvinced that improvement of pain on GnRH agents proves that the pain is solely of gynecologic origin. Conversely, failure of pain to improve on GnRH agonists does not invariably prove that pain associated with, for example, known endometriosis is not of gynecologic origin. In the former case, the medication may be treating irritable bowel components. In the latter case, a more aggressive laparoscopic surgical approach may be necessary.

More complete descriptive reports are needed that encompass multisystem evaluation, clinical and surgical approaches, pathologic findings, and outcomes. These reports would allow generation and further testing of hypotheses regarding appropriate treatments for the different components of pelvic pain and the relative value of operative intervention such as hysterectomy.

PELVIC ADHESIONS

Adhesions are more prevalent in women with chronic pain.^13,14 Contradictory reports have often used inappropriate control groups such as infertility patients, who may self-select for being pain free.¹⁵ Acute problems such as intestinal obstruction can occur in as many as 0.3% of benign adnexal gynecologic surgeries, 3% of hysterectomies, and 5% of radical hysterectomies.¹⁶ Autopsy studies reveal a 30% prevalence of pelvic adhesions in women who have never had pelvic surgery.¹⁷

The mechanism of pain production in women who do have pelvic adhesions is uncertain. Some adhesions seem to contain neuronal fibers, although the association of these fibers with pain is imprecise at best.¹⁸ More information concerning this association may appear in the future as a result of studies done using conscious pain mapping techniques and histologic assessment of adhesions.

The presence of adhesions is difficult to diagnose. By history, patients with significant adhesive disease may often describe that their pain is somewhat positional, such as being aggravated by assuming a sleeping position on one side or the other. The physical examination is inadequate to identify the presence and location of adhesions.¹⁹ Similarly, standard vaginal ultrasound, including observations of “slide-by” of adnexal structures compared with intestines, is not an accurate predictor of endoscopic findings.

Results of studies of the treatment of pelvic pain by adhesiolysis are somewhat encouraging. Only one controlled study has been performed. Peters and colleagues²⁰ performed diagnostic laparoscopy on 48 women and then randomly assigned one half of them to adhesiolysis by laparotomy and the other half to standard clinical management only. They found no difference in pain levels found between the two groups at 9 to 12 months postoperatively, except for improvement in those with severe bowel adhesions at the initial diagnostic laparoscopy. Unfortunately, a second-look laparoscopy to evaluate the regrowth of adhesions after the laparotomy was not performed.

Other studies have suggested that the laparoscopic approach to adhesiolysis results in less adhesion reformation than adhesiolysis by laparotomy.²¹ In general, the adhesion burden is reduced by approximately 50% after laparoscopic treatment.^22,23 Direct randomized comparison of laparoscopy with laparotomy for the treatment of pelvic adhesions associated with pain has never been performed.

Clinical series^24,25 suggest that 70% to 85% of women with chronic pelvic pain may obtain relief after laparoscopic adhesiolysis. The success rate may decline to less than 50% for those with complicating psychosocial factors described as a “chronic pain syndrome.”²⁵ Conscious pain mapping using microlaparoscopic techniques has been employed to obtain a better understanding of the visceral contributions to pelvic pain. Studies using this method may provide further information about the role of various types of adhesions in producing chronic pelvic pain. I expect to find that dense adhesions around the adnexal areas or dense adhesions of the small bowel to the pelvic floor or pelvic viscera may be most consistently associated with clinically important pain. A more complete discussion of this topic is provided elsewhere.²⁶

RETAINED OVARIES

A generation ago, gynecologists almost uniformly recommended bilateral oophorectomy at the time of hysterectomy for any woman undergoing the procedure who was older than 40 years of age. Because of generally changed treatment philosophies and patient wishes and because of the development of operative laparoscopy, the age at which oophorectomy is recommended has increased, and most texts refrain from offering a purely numeric recommendation. The variables to be considered in this decision include the patient’s age, obesity, past surgical history, risk of ovarian cancer, history of past pelvic infectious disease, presence of endometriosis, and her own personal preferences.

A major reason for recommending oophorectomy at the time of hysterectomy was that reoperation for ovarian problems occurred in approximately 1% to 5% of women who chose ovarian conservation at the time of abdominal hysterectomy.²⁷ When this problem required laparotomy, treatment entailed substantial operative and postoperative morbidity. Operative laparoscopy substantially reduces that morbidity, altering the decision parameters at the time of hysterectomy.

A “retained ovary” is defined as an ovary left behind after previous hysterectomy that has subsequently become symptomatic by virtue of intrinsic pathology, periovarian adhesions, or its location close to the vaginal apex. Associated symptoms typically include unilateral cyclic pelvic pain and deep dyspareunia. Variations occur, including more continuous discomforts and associated bowel dysfunction. In such cases, it is difficult to separate the contributions of general pelvic adhesive disease from those for which the ovaries are responsible.

Traditional surgical approaches to vaginal hysterectomy may contribute to this problem. Many versions of this procedure include suturing the utero-ovarian ligament into the vaginal cuff for purposes of augmenting vaginal apex support and extraperitonealizing any ligated or vascular pedicles.²⁸ This practice seems to have abated in recent years; it often resulted in the ovary being densely adhered to the vaginal apex, resulting in postoperative dyspareunia.

The traditional recommendation for women with endometriosis included bilateral oophorectomy at the time of hysterectomy when that procedure was performed. The literature suggests that the probability of requiring further abdominal surgery is approximately sixfold higher when one or both ovaries are left behind at the time of hysterectomy for endometriosis.²⁹ Although this is generally true, many surgeons are reluctant to perform bilateral oophorectomy when the degree of disease is minimal. A reasonable judgment may be to leave one ovary behind in the absence of overt disease in that ovary, provided complete surgical resection of visible disease is possible. Later operative intervention sometimes may be necessary, but it can almost always be accomplished laparoscopically. Other variables in this decision include the age of the patient, the pace of progression of endometriosis and her symptoms, and her wishes in terms in terms of ovarian conservation, hormonal replacement, and other issues. Because the behavior of endometriosis varies over time, it would be most informative to develop chronologic series in which ovarian conservation was practiced, with results stratified by degree of endometriosis present initially.

The diagnosis of the retained ovary syndrome is made primarily on the basis of clinical history and bimanual examination, sometimes supplemented by transvaginal ultrasound. In many cases, the final diagnosis cannot be made until laparoscopy is performed.

The typical history for retained ovary syndrome records a good level of postoperative comfort until approximately 4 to 12 months after hysterectomy. During this interval, the cyclicity of ovarian function may be disturbed, and the timing of exacerbations of pain may be somewhat variable. Words used to describe the pain typically include “dull” or “aching” with some sharp exacerbations. Especially when the left ovary is involved, alterations of bowel function can accompany the process, including increased pain with defecation. Constipation may aggravate the problem.

Bimanual examination often localizes pain to the area of either ovary. When the ovary is surrounded by adhesions, it may become progressively more difficult to outline and move. During the examination, transvaginal palpation of the ovary without the abdominal hand may replicate the patient’s dyspareunia.

Transvaginal ultrasound is sometimes used to estimate the proximity of the ovary to the vaginal apex. However, I have observed multiple false-positive results using this approach, probably because the transvaginal ultrasound probe can be manipulated over an extensive range, giving the false impression of proximity to the ovary.

When the symptoms associated with the ovary are caused by intrinsic ovarian function or dysfunction, suppression of the ovary may be useful diagnostically and therapeutically. Cyclic or continuous birth control pills or GnRH agonists may be employed. When GnRH agonists are used, they may reduce symptoms arising from irritable bowel disorder, confusing the diagnostic impression. In some cases, when medical therapy can be successfully employed for approximately 1 year after surgery, ovarian cyclicity may return and the degree of discomfort diminish. During this time, some couples are successful in adjusting coital technique to avoid the dyspareunia.³⁰

The surgical approach to the retained ovary is usually salpingo-oophorectomy. In the past, when laparotomy was needed to accomplish the procedure, the standard was removal of the innocent and the symptomatic ovary. The availability of laparoscopic techniques may allow exception to this rule. The soundness of leaving one ovary in place has not been systematically investigated. I make this decision with the patient based on her general level of concern about ovarian hormone replacement, the potential need for future surgery, and the difficulty of her past surgeries.

It is sometimes tempting to consider ovaripexy—mobilizing the ovary from the pelvic floor or the vaginal apex and suturing it to the pelvic sidewall or to the more lateral portion of the round ligament. The literature on this approach is scanty in terms of assessing postoperative comfort levels, and my experience with this technique is most disappointing.

OVARIAN REMNANT

A residual ovary is a normal ovary intentionally left in place. An ovarian remnant is diagnosed when both ovaries have ostensibly been removed at the time of previous surgery, but true ovarian tissue reemerges over time. Once felt to be uncommon, recent series suggested that this problem was more common than previously thought.^31,32 In most situations, it arises when the initial hysterectomy and oophorectomy surgery was difficult because of severe pelvic adhesive disease or endometriosis. A small fragment of ovarian tissue may be left behind in a bed of dense scar tissue. As peripheral levels of ovarian hormone subsequently decline, follicle-stimulating hormone (FSH) levels rise, stimulating the fragment to enlarge over time. Typically, a mass becomes diagnosable and symptomatic 1 to 3 years after the purported oophorectomy.

In its purest form, the ovarian remnant manifests as a cyclically painful, unilateral adnexal mass that is palpable on bimanual pelvic examination and can be visualized by transvaginal ultrasound, magnetic resonance imaging (MRI), or computed tomography (CT) scan. Premenopausal levels of FSH and estrogen demonstrate continued ovarian function.

Unfortunately, many ovarian remnants manifest in a more subtle fashion. I have operated on five histologically proven ovarian remnants that were not hormonally functional. Peripheral estrogen levels were at the upper end of the menopausal range, and FSH levels were between 80 and 90 mIU/ml. A number of other ovarian remnants were found in the presence of FSH levels that were only minimally elevated into the menopausal range.

Ultrasound and MRI studies of ovarian remnants are fallible; ultrasound images especially may be corrupted by the presence of postoperative adhesions involving adjacent loops of bowel or sterile inflammatory cysts. As a rule of thumb, many gynecologists have learned that the diagnosis of an ovarian remnant or other pelvic mass is uncertain when it rests only on the pelvic ultrasound results.

In many clinical situations, it is difficult to determine the relative contributions of the functional ovarian tissue compared with pain emerging from dense pelvic adhesive disease. In this setting, total ovarian suppression by a GnRH agonist may be informative. In cases not involving endometriosis, I use “add-back” estrogen replacement to reduce clinical symptoms. When these manipulations completely eliminate the pelvic pain, the ovarian remnant can be held responsible for the problem. In patients who are very poor operative candidates or who are close to the age of anticipated menopause, medical management in this manner can be continued until the remnant stops functioning. In my experience, monthly injections of GnRH agonists have not always been necessary; I have a number of patients managed successfully on GnRH agonist injections three to six times yearly.

The surgical approach to an ovarian remnant can be made by laparoscopy or laparotomy. The literature suggests a list of 10% to 15% of recurrence of ovarian remnant tissue even after the most careful surgical excision done by a laparotomy.³³ Comparable figures after laparoscopic removal of remnants have not been published. My experience is that the approach can be carried out by laparoscopy successfully when the anatomy is less complicated. After performing a thorough bowel preparation, it is almost always reasonable to start the procedure laparoscopically, with the proviso that laparotomy be carried out if necessary.

The timing of the surgery is important. If GnRH agonist suppression has been used as a diagnostic manipulation, it may succeed in making the remnant ovarian tissue so small as to be very difficult to find at the time of surgery. It is therefore prudent to allow some time to elapse after the last GnRH agonist injection and to reevaluate to be certain that the residual mass is again palpable if not imagable. The remnant may be provoked to enlarge by administering clomiphene (100 mg each day for 5 days), starting 10 days to 2 weeks before the procedure.

Regardless of the surgical approach, ureteral visualization is imperative. When performed laparo scopically, visualization may be aided by placing ureteral stents by means of cystoscopy at the beginning of the procedure. Whether performed laparoscopically or by laparotomy, dissection should be fundamentally the same, beginning with retroperitoneal entry lateral to the remnant, isolation of its vascular supplies (which usually involve the infundibular pelvic circulation), and separation of these structures from the ureter. After the vascular supply has been divided, further sharp and blunt dissection with mobilization of the ureter usually frees the mass from the surrounding tissue. Especially when this surgery involves endometriosis, it can be one of the more difficult benign gynecologic surgeries performed.

A number of techniques may more adequately identify the boundaries of surrounding structures, prevent injury to them, or evaluate them for the possibility of injury. In terms of the urinary tract, these techniques may include an intentional cystotomy over the dome of the bladder with retrograde stent placement, if stents have not been placed preoperatively, and intravenous methylene blue injection to evaluate the possibility of ureteral injury. The dye can be visualized cystoscopically or through the intentional cystotomy. At times, performing the intentional cystotomy may aid the precise definition of the bladder and the adjacent ureter while dissecting off the last portions of ovarian tissue.

Definition of the vaginal apex can be problematic at times. Placement of a stent in the vagina can help. I often place a patient in modified lithotomy position, allowing access to the vagina and the rectum during this type of procedure. This allows standard rectovaginal examination during the surgery, assisting definition of the vaginal apex and the rectum adjacent to remnant ovarian tissue.

Preoperative assessment usually determines the anticipated degree of difficulty of the surgery with reasonable accuracy. When an especially difficult case is anticipated, it should be tackled by the most experienced surgical hands available.

VAGINAL APEX REVISION

Uncommonly, deep dyspareunia is reported despite an appropriately performed and successfully completed hysterectomy. In the context of a referral pelvic pain practice, I have seen approximately 40 women during the past several years who appear to have pain that originates from the suture line of the vaginal cuff itself. As physicians have become more aware of this phenomenon, the diagnosis is made more frequently, and its true prevalence is open to speculation.

The clinical diagnosis is made by altering the usual technique of the pelvic examination. For this problem, commonly suspected on the basis of clinical history, I usually perform a speculum examination first. Total visualization of the vaginal apex is accomplished without directly touching it with the speculum. Touching the suture line with a cotton-tipped applicator allows mapping of focally tender areas. Typically, the tenderness is localized in one vaginal fornix or the other, although occasionally it can be present along the entire suture line. Observing that complete pain syndrome can be evoked by gentle palpation, it would appear that intraperitoneal pathology, even when present, may not be the culprit.

This diagnostic impression can be confirmed by painting the vaginal apex with a 2% Xylocaine gel and rechecking the same examination several minutes later. If this yields an inconclusive impression, the area can be injected with a 1% Xylocaine solution, buffered with 1.0 ml of 0.9% sodium bicarbonate per 10 ml of 1% Xylocaine. When technically feasible, to diminish the pain of injection itself, I use a 10-ml syringe equipped with a 27-gauge needle.

This diagnostic method may also be therapeutic. This type of injection can sometimes afford days or weeks of relief of the symptom, making the sensitive vaginal apex appear more like a trigger point. Occasionally, serial injections of this type have been successful in relieving the dyspareunia when coupled with suggestions for altering coital technique to limit deep penetration. In a few instances, the precoital application of a small amount of 2% Xylocaine gel through a transvaginal cream applicator has provided sufficient comfort to allow more comfortable intercourse. However, in most cases, obtaining sufficient relief requires enough volume of Xylocaine gel that the male partner is then gifted with temporary genital anesthesia, an unhappy outcome for both partners.

For most patients who do not succeed with these medical treatment methods, I usually offer revision of the vaginal apex. Although I have seen this performed by open laparotomy, it can almost always be accomplished laparoscopically with far less trauma to the patient. A complete description of this procedure is described elsewhere.³⁴ The surgeon places a vaginal stent in the vagina, fills the bladder to identify its margin, and incises the peritoneum adjacent to the bladder to allow blunt and sharp dissection to separate the bladder from the vaginal apex. After a reasonable surgical margin is obtained, a unipolar needle or scissors can be used to make an elliptical incision encompassing the vaginal apex suture line with an adjacent margin of approximately 0.5 cm. Once colpotomy is obtained, the remainder of the incision can be completed with the unipolar needle or with cautery scissors. The specimen is then removed through laparoscopic trocar and the vaginal apex reclosed laparoscopically or vaginally, depending on the particular anatomy. I usually completed the closure laparoscopically, because I think this ensures precise approximation of the vaginal edges. Interrupted or figure-of-eight sutures of 0 or 00 delayed absorbable suture may be employed using a regular needle driver or laparoscopic suturing device.

With follow-up ranging between 1 and 3 years, postoperative success has been obtained in all but 2 of 20 cases operated. The 2 failures have had recurrence of pain at the same level as that experienced preoperatively. Pathologic findings have included scarring in most, with about one half of the specimens containing additional findings such as sterile abscesses, residual endometriosis, and fluid-filled inclusion cysts.

PRESACRAL NEURECTOMY

Presacral neurectomy is defined as the surgical division of the sympathetic nerve supply traversing the superior hypogastric plexus. This plexus arises from the lower thoracic sympathetic chain, crosses anterior to the common iliac vessels on both sides, and forms a highly variable network in front of the fifth lumbar and first sacral vertebrae. It continues inferiorly to the inferior hypogastric plexus and thence to supply the uterus and adjacent tissues, including a portion of the bladder and the rectum. In this course, some of the fibers also traverse Frankenhauser’s plexus. Elant described a variation of this anatomy in a cadaver study published in the early 1930s.³⁵ In addition to anatomic variability over the sacral promontory, it appears that the ultimate destination of these fibers is also variable. The failures of interruption of the nerve supply to cure all forms of central pelvic pain is often attributed to redundant nerve supply emerging from other sympathetic fibers not traveling with this plexus and to parasympathetic fibers emerging from S2 through S4 nerve segments and arriving at the central pelvis through Frankenhauser’s plexus.³⁶

Originally described by Jaboulay in 1899,³⁷ presacral neurectomy was popularized by Cotte beginning in the 1920s. The latter investigator ultimately reported more than 1500 cases of successful treatment of central pelvic pain and dysmenorrhea with this procedure.³⁸ These early reports were extremely optimistic, reporting 98% success rates with almost no complications. Later reports by such gynecologic authorities as Pfanneuf³⁹ and Meigs⁴⁰ for more selectively performed procedures found an approximately 5% to 15% incidence of clinically significant constipation and urinary retention.

The procedure was used most frequently for the treatment of dysmenorrhea until the early 1960s. After the introduction of the oral contraceptive pill in the mid-1960s and the development of nonsteroidal inflammatory drugs in the early 1970s, the frequency of this procedure declined further.

In the 1970s and 1980s, presacral neurectomy remained in the surgical armamentarium primarily as a supplement to conservative resection for stage III or IV endometriosis. A number of open clinical trials suggested that the adding presacral neurectomy to conservative resection improved postoperative pain relief^41,42 Two randomized trials of the procedure have been done, both performed with women undergoing conservative resection of stage III or IV endometriosis. The trial reported by Tjaden and coworkers⁴³ described conservative resection by laparotomy in eight women, four of whom also underwent presacral neurectomy. Those who underwent neurectomy obtained complete relief, but none of the women with conservative resection only reported relief of pain. At that point, statistical significance was reached, and the study was terminated by the institutional review board. In a subsequent clinical series of presacral neurectomy with conservative resection, 15 of 17 patients reported pain relief. The second trial is that performed by Candiani and associates,⁴⁴ who reported essentially the same study in 71 patients. In this study, both groups obtained significant postoperative pain relief in terms of dysmenorrhea, pelvic pain, and deep dyspareunia. The addition of the presacral neurectomy apparently provided incremental improvement in central dysmenorrhea only, beyond that already attributed to conservative resection of endometriosis. One year postoperatively, both groups had similar rates of continued pain relief (80% versus 75%).

The added benefit of presacral neurectomy to thorough surgical resection of endometriosis remains in question. I think it should be carefully and selectively applied in the surgical management of chronic pelvic pain. Further work is needed to quantify the impact of this procedure on large bowel motility and bladder function. Sexual dysfunction after presacral neurectomy has not been investigated. If an argument can reasonably be made for preservation of the cervix in the interest of preserving sexual function, the physician must examine the presacral neurectomy patient for the possibility of impaired sexual response.

UTEROVAGINAL GANGLION INCISION

The uterovaginal ganglion incision is described briefly, if only as a cautionary note. The uterovaginal ganglion is a neurologic structure containing sympathetic and parasympathetic fibers and present near the ascending vaginal artery, ureter, and pelvic sidewall. It is unclear whether this is distinct from or is a part of Frankenhauser’s plexus.³⁶ Laparoscopic surgical interruption of this ganglion has been recommended by one investigator.⁴⁵ In her series of 175 patients who underwent bilateral uterovaginal ganglion ablation, two thirds reported significant relief and one third reported improvement, with only a 3% failure rate. However, as part of the diagnostic evaluation, she employed a pudendal nerve latency test that has not been validated and most likely represents evaluation of motor function, rather than sensory. In her report, success was highly correlated with return of this test result to normal values, which is most unusual in nerve conduction studies. Approximately 60% of the subjects had other procedures such as resection of endometriosis performed at the same time as the neuroablative procedure, making it difficult to assess the true outcome. No postoperative urodynamic studies, voiding diaries, or other attempts were made to look for complications. Some patients were reported as having urinary retention postoperatively, requiring permanent catheterization. A study of similar size reported this same procedure being applied for the treatment of “lateral pelvic pain,” otherwise undefined. Similar outcomes were described, although many of the patients undergoing this procedure for relief of bladder complaints also had excision of endometriosis. Potential overlap between these series was not described.

Although this type of selective denervation approach may prove fruitful for some pelvic pain conditions, the potential for complications is significant, and the procedures require careful development under structured research protocol conditions.

CONCLUSIONS

Extant organic pathology by no means establishes a connection between the pathology and the clinical pain reported. Thorough history, careful pelvic examination by techniques somewhat different from those usually employed, and laparoscopic pain mapping may in some cases provide important supportive evidence in favor of such a connection or may point to other sources of pain. These additional contributing factors need to be evaluated and treated to a degree possible before embarking on a surgical approach. A woman undergoing an operation for pelvic pain deserves complete discussion of the pros and cons of the procedure, including the potential for failure and the potential for inducing postoperative adhesive disease that may simply replace one painful condition with another. Often, this discussion should include the notion that recovery from pain, especially if present for a long time, may require a rehabilitation approach, rather than the hope that the surgery can eliminate the pain in short order.

The surgical approach chosen should fit the clinical and anatomic situation discovered and the experience and skills of the surgeon. In particular, the degree to which laparoscopic procedures are successful is more often caused by the experience and skill of the surgeon than it is to inherent limitations of the technique itself. The value of the best surgery lies in incorporating the procedure into an overall treatment plan that carefully evaluates and treats as many of the components of a chronic pain problem as possible.

Strangulated adnexa due to adhesion band after hysterectomy

Description

A 50-year-old woman was admitted to our hospital with a 2-day history of cramping pain of the lower abdomen. She also reported an episode of nausea and vomiting prior to admission. The patient had undergone total abdominal hysterectomy for uterine myoma. Her blood pressure was 100/60 mm Hg, pulse rate of 70 beats/min and axillary temperature of 36.5°C. The patient had mild direct tenderness of the lower abdomen, especially at the right lower quadrant, with no rebound tenderness or muscular guarding. Laboratory data showed a white cell count of 10 100/mm³ (normal limit of 4000–10 000/mm³) and a C reactive protein concentration of 17.25 mg/L (normal limit of 0–10 mg/L). A plain chest X-ray revealed no free air under diaphragm. Pelvic ultrasound demonstrated smooth bilocular cystic tumour within the right adnexa that has no colour flow on Doppler.

Contrast-enhanced abdominal CT showed a hypodense area measuring 4×3×3 cm in the region of right adnexa and a band-like structure (figure 1).

Figure 1

Strangulated adnexa due to an adhesive band in a 50-year-old woman (A). (B) Contrast-enhanced axial CT shows an adhesive band and a 4×3×3 cm hypodense right adnexal structure and an adhesive band, which represents a dilated adnexa in the right ovarian fossa.

Under general anaesthesia, emergency laparoscopy was performed. The laparoscopic findings revealed a 4×3×3 cm dark, haemorrhagic, edematous and strangulated right adnexa with adhesion band (figure 2). After removal of the adhesion band, the pedicle of the ovary and the tube were carefully examined. No improved colour or oedema was observed. The right adnexectomy was performed. Histological examination of the surgical specimen confirmed haemorrhagic infarction. The patient made an uneventful postoperative recovery and was discharged home on the third postoperative day.

Figure 2

Laparoscopic aspects of the 4 cm dark haemorrhagic oedematous right adnexa with an adhesive band.

Pelvic adhesion is a condition in which different tissues or organs are bound with fibrotic tissues in the pelvis. The incidence rate of adhesion varied from ≥90% in laparotomy to 55%–100% with common pelvic surgery.1 The severity of adhesion varied individually involving either two tissues bound with a very thin band-like film or a slightly partial band, while others may present with a tendon-like band that was thicker than a finger resulting in serious complications.

Strangulation due to adhesion band presents similar symptoms including severe pain of the abdomen, pelvis and lower back. Such pain may radiate to the lateral abdomen or the inguinal region. It is difficult to predict strangulation of appendages preoperatively.

In case of this study, the patient was an aerobics instructor, and the trapping of uterine adnexa by adhesion band was attributed to excessive physical exercise. It results in a gradual onset of abnormal flow of venous and lymphatic blood causing necrosis of uterine adnexa by strangulation due to increased size of uterine adnexa.

Problems of adhesion have been underestimated in current clinical practices, and most cases were detected by other practitioners several years after the original surgery.2 Clinical prevention of adhesion warrants careful haemostasis, gentle tissue handling, precise removal of necrotic tissue, minimisation of ischaemia, surgery to reduce infection and use of response-free suture materials.

Learning points

• Strangulated adnexa due to an adhesion band represent an extremely rare gynaecological emergency in women with a history of total hysterectomy presenting with acute abdominal pain.

• Early operative intervention preferably via laparoscopy is warranted to preserve ovarian function.

• Clinical prevention of adhesion requires careful haemostasis, gentle tissue handling, precise removal of necrotic tissue, minimisation of ischaemia, surgery to reduce the infection and use of response-free suture materials.

90,000 Signs of abdominal adhesions. Causes of development, treatment

Signs of abdominal adhesions, development, treatment

Adhesions often occur after surgical interventions on the abdominal organs. It can proceed without any manifestations, but it can also cause quite pronounced discomfort. In some cases, the adhesive process occurs outside of surgical interventions and not only in the abdominal cavity.The idea of ​​this pathology, including what is the adhesion process in the small pelvis in women, will help to seek medical help in time.

Dynamics of the development of adhesive disease in the abdominal cavity

All organs of the abdominal cavity are surrounded by the peritoneum, which serves as their protection from damage. If some pathological process (often inflammatory) occurs in an organ, fibrin fibers fall out in this place, which form adhesions that limit this location from healthy organs.This process starts with a perforated stomach ulcer, destructive appendicitis, and so on. Also, adhesions can occur in the abdominal cavity as a result of surgical intervention as a reaction to the touch of surgical instruments, contact with talcum powder, which is used to treat surgical gloves, and so on.

Due to the presence of adhesions, the abdominal organs stick together. The result of such bonding will be a violation of the blood supply to the organ and its functions.So, if adhesions are formed between the loops of the intestine, intestinal obstruction is formed – there is a violation of the stool, pain in the abdomen, which are signs of an adhesions in the abdominal cavity.

In the international classification of diseases, the adhesive process in the abdominal cavity and small pelvis is considered separately.

Causes of the adhesions in the abdominal cavity

This pathological condition can develop for a variety of reasons. There are three main groups of factors that can provoke the formation of adhesions:

1. Mechanical injuries.These are abdominal injuries from a fall from a height, a bullet or knife wound, as a result of surgery.
2. Diseases of the abdominal cavity organs of an inflammatory nature. So, adhesive disease can develop as a result of the current or after the transferred cholecystitis (inflammation of the gallbladder), enteritis (inflammation of the small intestine), adnexitis (inflammation of the ovaries), and so on.
3. Chemical damage to the abdominal organs. Most often observed with the outpouring of bile or stomach contents (for example, when a perforated stomach ulcer occurs).

Adhesion often occurs in the small pelvis. It can develop rapidly, with characteristic symptoms, or be asymptomatic. So, adhesions after a cesarean section often do not appear in any way. They can be diagnosed when a woman turns to a doctor about the impossibility of getting pregnant again, since the adhesion process in the small pelvis can provoke female infertility.

Pain with intestinal adhesions and other signs

There are several signs that may indicate the development of the pathological process under consideration:

• intermittent vomiting that occurs regardless of food intake;
• pain in the abdomen or chest cavity;
• chronic constipation;
• violation of gas discharge.

These are characteristic features of the adhesion process. Pain with adhesions in the intestines may not depend on food intake and increases over time. Symptoms of diaphragmatic adhesions are manifested by pain at the border between the thoracic and abdominal cavity, impaired excursion (movement) of the diaphragm, and difficulty breathing. Clinical symptoms of adhesions in the small pelvis may be absent.

Adhesive disease is long-term: abdominal pain occurs frequently, then becomes constant, its intensity increases.

Treatment of adhesions

Treatment of postoperative adhesions is carried out using conservative and surgical methods. They are in no hurry to resort to surgical treatment, since re-introduction into the abdominal cavity can provoke an even greater development of the adhesive process. The operation is performed without fail if critical changes occur in the abdominal cavity. The severity of adhesions can only be determined during an operation – for example, performed for intestinal obstruction.The most effective method for removing adhesions that have formed around the fallopian tubes is laparoscopic surgery. The recovery process after such treatment proceeds quickly and with minimal risk of complications. At the heart of the conservative treatment of adhesive disease are diet (restriction of coarse fiber food) and physiotherapy methods.

How to treat adhesions after appendectomy, the doctor decides – it can be surgery or conservative methods of treatment (diet, physiotherapy).In the early stages of the development of the adhesive process, it can be influenced by conservative methods. Medical treatment of the adhesions can also be prescribed in gynecology – for adhesions that have arisen in the area of ​​the appendages, vaginal suppositories are used, but such therapy is not very effective.

In the event of adhesions after removal of the uterus, treatment is extremely rare, since they do not cause a feeling of discomfort, and reproductive function is in any case lost forever. The doctor determines the feasibility of treating the adhesions in this case, based on the complaints of the patients.

More detailed information on pathology, including the causes of adhesions in the chest cavity, can be obtained on our website https://www.dobrobut.com/.

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Intestinal adhesions after surgery – symptoms of adhesions in the small pelvis and their treatment in ON CLINIC in Ryazan

Adhesive disease is a pathology characterized by excessive proliferation of connective tissue.According to statistics, adhesions of the small pelvis are most often found as a result of all kinds of female diseases. In addition, a common pathology is intestinal adhesions, in which connective tissue elements – the so-called strands – are formed between its loops and other internal organs located in the pelvic region. Most often, after surgery, intestinal adhesions occur – in patients who have had 3 or more laparotomy interventions in the abdominal cavity, they appear in 97 cases out of 100.

As for such a disease of the representatives of the beautiful half of humanity, as adhesions of the small pelvis, many factors can affect their appearance.In principle, the proliferation of connective tissue in order to avoid the spread of the inflammatory process is a natural reaction of the body to factors that threaten its normal functioning. These include:

• inflammation of the internal organs located in the lower abdomen – appendages, uterus, etc. This can be, for example, a consequence of endometriosis. Inflammatory diseases caused by infection of the pelvic organs are also common. Often, abortion, too long use of an intrauterine contraceptive, as well as all kinds of STDs lead to infection;
• often pelvic adhesions are a consequence of previous appendicitis or intra-abdominal hemorrhage.For example, rupture of the ovary due to an ectopic pregnancy can eventually “backfire” with just such a complication as pelvic adhesions.

Adhesive disease is one of the reasons that gynecological diseases and intestinal lesions must be promptly treated with water by the supervision of a specialist. The fact is that the proliferation of connective tissue is not accompanied by an acute phase of the disease, but its chronicity. That is why, when qualified treatment is started on time, the risk of adhesion formation is reduced tenfold!

Adhesions: symptoms

The severity of the manifestations of pathology depends primarily on how far the pathological proliferation of connective tissue has gone.Often, adhesive disease is asymptomatic. However, experts distinguish three types of the course of the disease – each with its characteristic clinical manifestations:

• acute, in which the symptoms of adhesions are quite pronounced and become more and more intense over time. It is accompanied by abdominal pain, fever, nausea and vomiting. Sometimes to all these signs of the disease is added such a complication as dangerous for the health and life of the patient, such as intestinal obstruction;
• sluggish, which is manifested by periodic soreness of the abdomen and unstable stools;
• chronic with asymptomatic course.It is often the cause of infertility.

Identification and treatment of adhesions in Ryazan in our private clinic

An experienced gynecologist – and these are the specialists who receive patients at ON CLINIC in Ryazan – may suspect the presence of adhesive disease in a patient already during a routine examination on an armchair. Nevertheless, to confirm the preliminary diagnosis, some instrumental studies will be needed – in particular, ultrasound of the pelvis and ultrasound of the abdominal cavity.Depending on the results of the examination, the optimal treatment tactics for adhesions are prescribed.

If adhesions – after surgery or arising for any other reason – have just begun to form, then the use of special fibrin-dissolving drugs can help to achieve a good effect. It is especially good to use them in combination with physiotherapy procedures.

However, in most cases, surgery is the only effective technique to get rid of adhesions.Today, such surgical interventions are performed not in the classical – abdominal – way, but through small punctures in the anterior abdominal wall. Under the control of a miniature video camera, the connective tissue is excised mechanically, with a laser or with an electric knife. The introduction of a special solution into the peritoneum at the end of the intervention minimizes the risk of re-formation of adhesions after surgery.

Are you interested in the price of treatment of adhesions in Ryazan in our private clinic? Call us and make an appointment!

Treatment of adhesions with osteopathy without surgery – patient reviews, St. Petersburg, MC Wise Doctor

Millions of people around the world have found themselves on the operating table at least once in their lives.As a rule, operations – both planned and emergency – are successful, and after the rehabilitation period, the person returns to the usual way of life. Nevertheless, osteopathic doctors note that any surgical intervention – even if it was performed by the laparoscopic method – can negatively affect the functioning of internal organs if the patient develops an adhesive process.

Adhesions after surgery on the abdominal organs – after appendicitis, surgery on the intestines, removal of the uterus and other surgical procedures in the field of gynecology – as well as after surgery on the spine are one of the most common complications.As practice shows, it is in the first time after surgery that it is easiest to prevent the development of the adhesions, as well as to eliminate the already formed adhesions.

In the first weeks and months after the operation, the treatment of adhesions with osteopathy is especially effective! Usually one or two sessions with an osteopath are enough for this.

Postoperative adhesions – formation mechanism

The internal organs of a person are covered with a thin translucent film – the serous membrane.Inside the abdomen, this is the so-called peritoneum, which lines the outside of the pelvic organs, stomach and intestines, in the chest cavity it covers the lungs of the pleura. In a healthy person, the leaves of the serous membranes are mobile – sliding gently, thereby giving the organs the opportunity to function fully.

However, mechanical damage to internal organs – including the excision of their parts during surgery – or an inflammatory process can cause damage to these serous membranes.In an effort to restore their integrity, the body begins to replace the damaged area of ​​the film with connective tissue fibers, which pull together the sheets of serous membranes, preventing them from sliding relative to each other and forming inelastic constrictions. It is these constrictions that experts call spikes.

As for the internal organs, they have their own ligaments – flexible, elastic, helping the organs to hold in place and at the same time providing the proper level of their physiological mobility.Injuries and some diseases can cause deformation of these ligaments – their thickening, uneven density distribution over their constituent tissue and fusion of ligament fragments with organs. Such violations provoke the displacement of internal organs, as well as the appearance in the intra-abdominal and / or pleural space of the so-called zones of excessive tension. So, the ligaments holding the stomach in a pathologically taut state can cause the patient to have pain in the back.Over time, the adhesion process can grow, forming extended chains of inelastic connections of organs, tissues and ligaments. And a similar chain, directed, for example, from the gallbladder through the liver and diaphragm to the region of the heart, can provoke chest pain in a person. In this case, the treatment prescribed by the cardiologist will be ineffective or completely useless, because the cause of the pain in this case will be the surgical intervention performed on the gallbladder several years ago!

So, adhesions in the pelvic area can form as a result of an operation performed – abortion, removal of the uterus or fallopian tube, etc.as well as due to inflammation. A pronounced inflammatory process can be accompanied, among other things, by such gynecological diseases as endometriosis, inflammation of the appendages, adenomyosis, etc.

Reasons for the development of the adhesive process

The main factors provoking the formation of adhesions are:

• inflammatory process. Both the process itself and the addition of bacterial infection to it can cause damage to the serous membranes enveloping the internal organs.An example is the development of an adhesive process in the chest due to pleurisy, and in the abdominal cavity due to peritonitis;
• surgical interventions performed. Both the laser, and the scalpel, and radio waves inevitably damage the serous membranes of the internal organs, which can cause the formation of fibrous adhesions after the operation;

90,019 injuries. Damage to the serous membranes in this case can also provoke the development of the adhesive process;

• Finally, in some cases, the adhesion process is activated in the absence of any apparent reason.Doctors believe that this is a consequence of heredity, unfavorable in this sense.

Postoperative adhesions: symptoms

Symptoms are due to which organs are involved in the pathological process. Thus, the presence of adhesions in the pleural cavity provokes frequent colds and / or shortness of breath in the patient, which, in turn, can significantly reduce his performance, increasing fatigue. Other symptoms of adhesions in the chest are pain and pressure in the region of the heart, as well as a persistent cough, for which drug treatment is ineffective.

In the absence of timely diagnosis and treatment, intestinal adhesions can cause gross deformation of its loops, difficulty in the passage of semi-digested food through them, problems with absorption of nutrients by the intestinal walls and, as a consequence, its gradual atrophic changes, and in the most advanced cases even lead to necrosis of a part intestinal wall. Intestinal adhesions can trigger the following symptoms in a patient:

• spastic abdominal pain, which can be of varying intensity, and, as a rule, become more pronounced at the time of physical activity or non-compliance with a diet;
• constipation – a consequence of deformation of the intestinal loops;

90,019 stool disorders;

• bloating, flatulence;
• Impaired absorption of nutrients by the intestinal wall can cause rapid weight loss in a patient.

There is also an asymptomatic course of the pathology. Nevertheless, you can be absolutely sure that if the patient has ever had an operation on the abdominal organs, then there are guaranteed adhesions in it.

If we talk about adhesions localized in the pelvic region, then they are manifested primarily by pain on palpation. The pain can be from barely perceptible to almost unbearable – the latter usually indicates an acute course of pathology. In addition, the patient may complain of nausea, vomiting, and stool disturbances.Finally, in women, adhesions in the pelvic area can cause menstrual irregularities, soreness during intercourse, and even infertility.

Treatment of adhesions in an osteopath

The unique ability of the body to independently compensate for various disorders of its functioning allows it to keep the serous membranes mutually mobile, and the ligaments elastic until a certain moment. However, the loss of their functional characteristics can lead to impaired mobility of internal organs.

Treatment of adhesions without surgery by the method of osteopathy, according to the opinions of patients of osteopathic doctors of our medical center in St. Petersburg, is a highly effective method that allows you to get rid of discomfort and pain in just a few sessions. This is a gentle technique that has no side effects and can be used for patients of any age and any health condition, allowing without surgery to restore mobility and normal functioning of internal organs.

During the session, the osteopath gently affects the patient’s internal organs, thereby restoring their normal position relative to each other and mobility, while simultaneously releasing pinched nerves and blood vessels.Such a manual effect stimulates the work of internal organs, having a beneficial effect on their condition and stimulating the restoration of the integrity of the serous membrane covering their surface. This not only eliminates the pathological tension of the ligaments, but also helps prevent the development of other diseases in patients – the consequences of the presence of overstrain areas in the body.

Along the way, the specialist restores normal lymph flow and blood circulation, and also normalizes muscle tone.At the same time, both atony and hypertonicity of muscles, including those that are part of the structure of internal organs, are eliminated.

Practically at any degree of the pathological process, treatment of adhesions by an osteopathic physician can achieve a lasting positive result. Of course, it is not possible to eliminate old adhesions without surgery; nevertheless, a specialist can restore normal mobility and functioning of even an internal organ with adhesions.

Active fight against adhesions – causes, diagnosis and treatment

No woman is 100% insured against the possibility of inflammatory diseases of the pelvic organs, such as endometritis, salpingitis, salpingo-oophoritis, from gynecological operations or intrauterine manipulations.It would seem that this is terrible? All these conditions are well known to medicine, and doctors have long learned to cope with them. But then why do most women get chronic inflammatory diseases, and after gynecological operations there are persistent pelvic pains?

The reasons can be any: from the usual decrease in immunity, which does not allow a timely cure of the acute process and translates it into a chronic form, to adhesions that form in a woman’s body at a time when she does not even think about it.

What are adhesions and how are they dangerous?

Adhesions are an overgrowth of connective tissue between the abdominal and pelvic organs. As a result, the uterus, fallopian tubes, ovaries, bowel loops are tightly “glued”, pulled to each other, and their functions are disrupted.

When do adhesions occur?

It is clinically proven that any operation or abortion can lead to the formation of adhesions. After surgery, adhesions develop in 55-100% of patients, and after gynecological operations – in 60-90% ¹ .Any inflammation or injury triggers a nonspecific response of the body – the proliferation of connective tissue. So the body tries to limit the focus of inflammation. Already in the first 3 days after the penetration of an infectious agent or violation of the integrity of the peritoneum or mucous membranes, fibrin adhesions are formed between organs and tissues. Then collagen and other forms of extracellular matrix are deposited in these delicate fibrin masses, transforming the adhesions into dense cords. Such adhesions can change the position of internal organs, which seem to “grow together”, which leads to disruption of their work ² .

How to prevent adhesions?

Enzyme preparations based on hyaluronidase can be used for the prevention and treatment of adhesions. This enzyme acts on the “skeleton” of connective tissue fibers. Unfortunately, natural hyaluronidase, introduced into the body, is quickly inactivated by enzymes and blood plasma inhibitors, without having time to exert its therapeutic effect. ³

Longidase is a new generation enzyme preparation based on hyaluronidase — Unlike the previous generation enzyme preparations, hyaluronidase in its composition is stabilized by a high molecular weight carrier, which allows it to remain resistant to the action of enzymes and to exert its therapeutic effect without hindrance.Longidase facilitates the movement of fluid in the intercellular space, which leads to a decrease in edema, resorption of hematomas and increases the availability of antibacterial drugs to the site of infection. In addition, a decrease in the viscosity of the connective tissue base under the influence of the drug increases the elasticity of the adhesions, which makes it possible to reduce pain (instructions for the Longidaza drug).

How does Longidaza work in different situations?

The acute phase of the onset of such diseases of the pelvic organs as endometritis, adnexitis and salpingitis cannot be missed in the daily rush.From the first days, the temperature rises, unpleasant discharge appears, and sharp pains in the lower abdomen make you forget about everything in the world. The most common cause of this is disease-causing bacteria. But not everyone knows that already at this moment the body itself starts the process of proliferation of connective tissue around the focus of inflammation, blocking the focus of infection. To avoid the formation of adhesions, doctors, together with antibacterial drugs, prescribe the enzyme Longidase, which prevents the development of adhesions, prevents the development of infertility and preserves the woman’s reproductive health. ⁴

Much more “insidious” are chronic sluggish inflammatory processes that go unnoticed for years, causing serious damage to the organs of the woman’s reproductive system. In chronic inflammation, adhesions have already formed, which means that drug therapy because of them reaches the focus of inflammation with great difficulty. In this case, it is not enough to ensure the prevention of the development of new adhesions – it is necessary to influence the existing ones in order to increase the access of antibacterial drugs to the focus of infection.Longidase reduces the swelling of inflamed tissues, increases the elasticity of the formed adhesions and prevents the formation of new ones, as a result of which the adhesion process decreases. ⁵

In cases of gynecological operations, injuries and abortions, adhesions are formed in the same way as in acute inflammation – from the third day of the disease. The inclusion of Longidase in complex treatment not only reduces the adhesion process, but also improves the body’s resistance to infections, and also provides a quick recovery after surgery, due to an increase in the woman’s immunity. ⁵

Can the drug be used alone?

Longidaz Suppositories are available over the counter without a prescription. However, in situations requiring the prescription of a drug, it is important to seek medical advice. It is the doctor who will select the correct duration of therapy and will tell you in detail about the drug use regimen.

What if the doctor did not prescribe enzyme preparations for pelvic inflammatory disease?

In inflammatory diseases, doctors prescribe antibiotics that act on the cause of the disease – an infectious agent.But we must not forget that the presence of inflammation in the abdominal cavity, in the internal genital organs of a woman creates conditions for triggering the mechanisms of the adhesive process from the third day of the disease. If the doctor has not prescribed a remedy for the prevention and treatment of adhesions, you should ask at what stage he plans to connect this therapy. It is important not to waste time, because adhesions are more successfully treated at the stage of “gentle adhesions” rather than “dense connective tissue strands”.

1. (De Wilde R.L., Trew G.Postoperativeabdominal adhesions and their prevention in gynecological surgery. Expert consensus position. Gynecol Surg 2007; 4: 161-8).
2. (Dubrovina SO Monograph “Adhesion process” Rostov-on-Don 2015).
3. “Some modern aspects of inflammatory diseases of the pelvic organs” Consilium Medicum 2015, Volume 17, No. 6.
4. (Fedorovich O.K., Matveev A.M., Pomortsev A.V. “The effectiveness of the use of anti-adhesion agents and Longidase in maintaining patency of the fallopian tubes after treatment of an uninterrupted tubal pregnancy”.Russian Bulletin of Obstetrician-Gynecologist 2014; 6:91 – 93).
5. (Strizhakov A.N., Pirogova M.N., Shakhlamova M.N. “Prevention and treatment of adhesions after surgical treatment of ovarian apoplexy” Russian Bulletin of Obstetrician-Gynecologist, 2015; 2: 36-42.

Sources

• Shah A., Patel V., Parmar B. Discovery of Some Antiviral Natural products to fight against Novel Corona Virus (SARS-CoV-2) using Insilico approach. // Comb Chem High Throughput Screen – 2020 – Vol – NNULL – p.; PMID: 32881661

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Laparoscopy. Scar Free Surgery | Medical Clinic PRAKTIK

Currently, modern medicine has made a big step forward. This applies, in particular, to gynecology. Women were given the opportunity to treat diseases of the reproductive system, which were previously imposed as a sentence. One of these methods of treatment can be considered laparoscopy.

Laparoscopy is a minimally invasive, that is, minimal surgical intervention, which allows not only an accurate diagnosis, but also immediately, if necessary, to carry out a series of surgical actions to treat the identified problem.Therefore, conditionally, laparoscopy is divided into diagnostic and therapeutic. Like any surgical operation, laparoscopy can also be planned and emergency.

The operation can be performed under general anesthesia. In the anterior abdominal wall, the doctor makes 3-4 five-millimeter holes, which are located in the groin area and near the patient’s navel. For better visual viewing and reducing the risk of injury to internal organs, carbon dioxide is pumped into the abdominal cavity. Then a thin tube with a video camera – a laparoscope – is inserted through one of the holes.

With the help of optics, the laparoscope transmits the video image to the monitor screen. The resulting picture is broadcast at 6x magnification. Through the remaining 2-3 holes, manipulator instruments are introduced into the inside, which the surgeon, like the laparoscope, controls from the outside. When the procedure is completed, the instruments are removed, the gas is released from the abdominal cavity, and the holes are sutured.

Thus, laparoscopy has a number of undoubted advantages over abdominal surgery:

• minimal blood loss;
• the operated organs are more clearly visible for the doctor;
• minor pain syndrome;
• good cosmetic effect;
• postoperative adhesions are not formed;
• short period of hospitalization;
• short rehabilitation period;
• Pregnancy planning after laparoscopy is possible as soon as possible.

Indications for scheduled laparoscopy in gynecology are:

• Removal of ovarian cysts and tumors
• Removal of myomatous nodes of the uterus
• Removal of the uterus (hysterectomy)
• Restoration of functional patency of fallopian tubes

External endometriosis and treatment

• Diagnosis and treatment of chronic pelvic pain
• Diagnosis and treatment of congenital malformations of the reproductive apparatus
• Diagnosis and treatment of polycystic ovaries (wedge resection and coagulation)
• Correction of prolapse and prolapse of the genital organs
• Diagnosis and treatment of causes of infertility
• IVF
• Sterilization procedure (tubal ligation)

Preparing for laparoscopy

Some women find laparoscopy safe and easy.This is in vain. Like any other surgery, laparoscopy has its potential risks. But you can reduce some of them yourself by simple, but strict adherence to all doctor’s recommendations during preparation for endoscopic intervention.

First of all, the patient must undergo a series of mandatory medical examinations:

• within ten days before the operation, general blood and urine tests are taken, the blood is examined for biochemical composition and coagulability, blood group and Rh factor;
• tests for HIV, syphilis and hepatitis C and B will be valid for three months;
• vaginal flora swab is valid for 10 days before surgery;
• an electrocardiogram and ultrasound of the pelvic organs are performed;
• in all cases, the therapist is obliged to issue a conclusion before hospitalization.

Before scheduled laparoscopy, food that causes bloating should be eliminated in three to four days. On the preoperative evening, a cleansing enema is performed. Eating and drinking is prohibited on the day of surgery. Some diseases require drug preparation before laparoscopy.

The cost of laparoscopy in the clinic is 25,000 rubles

Rehabilitation period after laparoscopy

After surgery, 3-4 5 mm long incisions remain on the abdominal skin.Patients begin to get out of bed a few hours after surgery. Discharge from the hospital is carried out the next day, after 24 hours. Anesthetic therapy is minimal. Within 1 week – a gentle diet.

With physical activity it is worth waiting for 1 month. Abstinence from sexual intercourse is necessary for two to three weeks. Disability recovery, as a rule, occurs on the 10-14th day after the operation.

Laparoscopy is carried out under high-quality anesthesia on modern equipment of the KARL STORZ company by experienced doctors of the PRAKTIK medical center

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Adhesions after removal of the uterus.Symptoms of adhesion formation after removal of the uterus

By 25 min. Hits 7 Published 12.24.2019 Updated 12.24.2019

How to preserve the uterus and quality of life

MD, professor Afanasyev Maxim Stanislavovich, oncologist, surgeon, gynecological oncologist, expert in the treatment of dysplasia and cervical cancer

Historically in medicine, the opinion was fixed that the uterus is needed only for bearing a child. Therefore, if a woman does not plan to give birth, she can safely resort to surgery.

Is this really so or not? Why, for example, in March 2015, Angelina Jolie removed both ovaries with fallopian tubes, but left the “unnecessary” uterus? Let’s find out together whether it is dangerous to remove the uterus. And if it is dangerous, then with what.

From the point of view of a surgeon, a radical operation solves the question “in the bud”: no organ – no problem. But in fact, the recommendations of surgeons can not always be perceived as objective. They often do not take patients after discharge, do not conduct examinations six months, a year, 2 years after the removal of the uterus, do not record complaints.Surgeons only operate and rarely face the consequences of the operation, therefore they often have a false idea about the safety of this operation.

1. (previously absent) pelvic pain of varying intensity,

2. bowel problems,

3. urinary incontinence,

4. vaginal prolapse and prolapse,

5. depression and depression, up to serious disorders psyche,

6.emotional and physiological problems in relations with a spouse,

7.in some women who were operated on for severe dysplasia or in situ cancer, there was a relapse of the disease – damage to the stump and vaginal vault.

8. fatigue,

9. persistent increase in blood pressure and other serious cardiovascular problems.

The problem is not invented, because according to the Scientific Center of Obstetrics, Gynecology and Perinatology of the Russian Academy of Medical Sciences, various operations to remove the uterus make up from 32 to 38.2% of all abdominal gynecological operations.In Russia, this is about 1,000,000 queen bees removed annually!

There is another side to the problem. Since all of these complications develop gradually, over a year or several years after surgery, women do not associate the deterioration in their quality of life with a previous operation.

I am writing this material so that you yourself can evaluate all the pros and cons of the operation, weigh the pros and cons, and consciously make your choice.

My practice shows that there are no extra organs. Even in older women, removal of the uterus has negative health consequences, and in the second part of this article I will dwell on them in detail.

I want to reassure those patients who are faced with a difficult choice – to agree to the removal of the uterus or not. In some cases, removal of the uterus can be avoided. About half of those diagnoses that were considered direct indications for surgery 10 years ago are now treated without surgery or without removal of the organ.

Adhesions after removal of the uterus and ovaries symptoms

The organs of the abdominal cavity are covered with a thin and smooth film that allows them to change position when a person moves. Adhesions are an overgrowth of connective tissue, gluing together internal organs.

This formation in the uterus is formed for various reasons, including after its removal. More than 90% of women operated on have this complication.

Adhesions after removal of the uterus are a dangerous consequence, they can lead to disruption of the functioning of internal organs.

Postoperative scars are a normal physiological condition that has nothing to do with a disease that requires removal of the fallopian tubes, ovaries or the uterus itself. As a result of amputation, connective tissue scars are always formed where the incisions were made. Reasons for the formation of the disease:

• duration of surgery;
• trauma to other anatomical structures of the abdominal cavity;
• violation of the serous layer of the intestine;
• Forgotten tampons, gauze or surgical instruments inside the pelvic organs;
• inflammatory processes;
• penetration of infections due to the negligence of doctors and unsterilized instruments prepared for hysterectomy;
• infection in the postoperative period;
• internal bleeding after surgery;
• Correctness of the cut.

The development of the adhesive process can begin due to the fact that the woman is too thin. In addition, the volume of blood loss and genetic predisposition affect the formation of physiological scars. The onset of the disease is caused by the absence in the body of a special enzyme capable of absorbing fibrin deposits.

Manifestations of the disease

Adhesions after surgery to remove the uterus in all women show almost the same symptoms. The clinical picture of the disease, depending on the progression of the disease:

• a rare visit to the toilet means the appearance of intestinal obstruction;
• the woman begins to suffer from frequent constipation, each time it becomes harder to defecate;
• cessation of stool discharge;
• the appearance of pain in the lower abdomen;
• worsening of the condition is manifested by nausea and vomiting;
• Touching the postoperative suture causes pain;
• in the presence of an external scar, it becomes red, swells severely;
• Fever may occur.

After removal of the uterus and ovaries, as a result of the formation of adhesions, flatulence and gas formation appear. During intercourse, a woman complains of pain, after which bloody mucus is released from the vagina. The disease can lead to necrosis of the intestine, peritonitis, ectopic pregnancy, menstrual irregularities.

After surgery, you should visit a doctor. He must monitor the condition of the woman in order to prevent such complications, detect the adhesive process in time and remove it.

After removal of the genital organ for preventive purposes, the patient is prescribed a course of drug treatment. Anti-inflammatory drugs, enzymes for resorption of scars will not allow the formation of an adhesive process. Antibacterial agents are also prescribed. If this treatment does not help, the only way out is surgery, which involves removing the scars.

After confirming the presence of an ailment using a clinical blood test, ultrasound of the abdominal cavity, X-ray or laparoscopic diagnostics, treatment should be started immediately.

To remove postoperative adhesions, doctors use 2 types of surgical intervention:

• laparoscopy;
• laparotomy.

Laparoscopy involves inserting a fiber optic tube into the abdominal cavity. With the help of special instruments inserted through 2-3 small incisions, the surgeon cuts the scars and cauterizes the bleeding vessels.

Laparotomy is used somewhat less frequently. This surgery is indicated in the presence of physiological adhesions in the abdominal cavity.Laparotomy is able to provide full access to internal organs.

Treatment of ailment with folk remedies has been practiced for a long time. Of course, the official luminaries of medicine are not enthusiastic about this method of treating adhesions, however, many doctors recommend using all means to prevent scar formation. The best recipes for disease:

1. Wrap 2 tbsp. l. flaxseed into a clean gauze bag. Dip the product in boiling water, no need to cook, just put it on, turn off the heat and wait for the water to cool.During this time, the seeds will be steamed. Now take flax, spread it in the lower abdomen for the night, wrap it on top with a film and a warm scarf. This remedy helps relieve pain.
2. Take 1 st. l. milk thistle seeds, pour a glass of boiling water, boil the product for 10 minutes. Then cool, strain. Take the medicine three times a day, 1 tbsp. l. Consume warm.
3. Use psyllium seeds. Prepare the medicine according to the previous prescription. The broth should be taken half an hour before meals 3 times a day.The duration of therapy is 1-2 months.

Postoperative adhesions respond well to treatment with such folk remedies as a decoction of milk thistle, cinquefoil, St. John’s wort, borax uterus. The effectiveness of therapy depends on the correct preparation of the drugs.

Remember that despite the relative safety of alternative treatment, before using the above recipes, you must obtain a doctor’s permission, self-treatment can harm the body.

Hysterectomy or removal of the uterus is a common operation in modern gynecology. Surgery to remove or amputate the uterus is often performed in women over forty. This is due to the fact that in patients of reproductive age, the removal of the uterus is performed only for serious indications.

Hysterectomy, implying amputation or removal of the uterus, is performed in the following clinical cases:

• rupture of the uterus during delivery;
• Intensive growth of benign tumors in postmenopausal women;
• malignant tumors of both the uterus and the appendages, as well as suspicion of an oncological process;
• prolapse of the uterus in the presence of concomitant pathologies.

Sometimes the removal of the uterus is performed with extensive injuries in the small pelvis and purulent peritonitis, which are characterized by a severe course. The question of amputation of the uterine body is decided on an individual basis and depends, first of all, on the severity of the pathologies, the presence of other diseases, the age and reproductive plans of the patient.

Hysterectomy can be performed in several ways.

1. The most common is supravaginal removal or amputation.
2. Extirpation of the uterine body with appendages implies amputation of both the cervix and both ovaries.
3. Total hysterectomy means the removal of the uterus together with the appendages, cervix, ovaries, local lymph nodes and affected tissues of the vagina. This type of removal is recommended for malignant uterine tumors.

Despite the prevalence of operations to remove the uterus, hysterectomy is recommended for serious indications. This is due to the fact that amputation of the uterus has operational and postoperative complications, as well as long-term consequences that significantly worsen the quality of a woman’s life.

Gynecologists note the following operational and postoperative complications.

• Inflammation and suppuration of the postoperative suture. In this case, edema, redness, and suppuration of the wound develop with possible symptoms of discrepancy of the postoperative sutures.
• Suture infection after surgery. Symptoms of infection include high fever and soreness. In order to prevent infection, the postoperative suture needs regular processing.
• Violation of urination. In the early postoperative period, cramps often occur during emptying of the bladder.

• Bleeding. This complication can occur both in the operational and postoperative period.
• Damage to adjacent organs. When the uterine body is amputated, damage to the walls of the bladder and other organs is possible.
• Pulmonary thromboembolism. This dangerous complication can cause blockage of the pulmonary artery by pieces of torn tissue.
• Intestinal paresis. It occurs against the background of damage to the nerve fibers of the small pelvis during surgery.
• Peritonitis. This pathology means inflammation that has spread to the abdominal region. If this postoperative complication is not eliminated in time, there is a threat of sepsis development. In this case, the woman has symptoms such as severe pain, loss of consciousness, an earthy skin tone, intense sweating, and high fever. Treatment consists of antibiotics and removal of the uterine stump.

The following manifestations are attributed to later consequences.

• Loss of reproductive function. Removal of the uterus entails the impossibility of carrying a pregnancy.
• Psychoemotional disorders. Hormonal fluctuations cause an unstable emotional background, depression, irritability.
• Decreased libido. A woman may notice a lack of sex drive. Sexual life is characterized by painfulness and psychological discomfort.
• Onset of symptoms of early menopause. After amputation of the uterine body, symptoms such as sweating, hot flashes, and fragility of bones appear.
• Development of the adhesive process. After any surgical intervention, the appearance of adhesions is considered inevitable.
• Cosmetic defect. Since the amputation of the uterus occurs most often through abdominal surgery, a noticeable scar remains.

After removal of the uterus by hysterectomy, postoperative adhesions develop, which can lead to unpleasant symptoms, for example, pain, defecation and urination disorders, displacement of the pelvic organs, prolapse of the vaginal walls.

Adhesions after uterine amputation are one of the most unpleasant consequences of the postoperative period. According to statistics, adhesions after surgery occur in more than 90% of women.

Adhesion process, despite its seeming harmlessness, is a serious postoperative complication.

The danger of the development of the adhesive process is that it can lead to serious diseases and cause unpleasant symptoms.

What are adhesions

• uterine rupture during delivery;
• Intensive growth of benign tumors in postmenopausal women;
• malignant tumors of both the uterus and the appendages, as well as suspicion of an oncological process;
• prolapse of the uterus in the presence of concomitant pathologies.

1. The most common is supravaginal removal or amputation.
2. Extirpation of the uterine body with appendages implies amputation of both the cervix and both ovaries.
3. Total hysterectomy means the removal of the uterus together with the appendages, cervix, ovaries, local lymph nodes and affected tissues of the vagina. This type of removal is recommended for malignant uterine tumors.

Absolute indications for the removal of the uterus

Thanks to the introduction of high-tech methods, some of the indications for the removal of genitals have ceased to be absolute indications.Here is a list of diagnoses in which the removal of the uterus in women can be replaced with other methods of treatment and the organ is preserved.

1. Symptomatic, overgrown, fast-growing uterine fibroids today are treated by embolization of the uterine arteries: the vessels supplying the fibroid are blocked. In the future, the myoma gradually dissolves.

2. Adenomyosis, or internal endometriosis, can be treated with the therapeutic method of photodynamic therapy (PDT).

With endometriosis, the cells of the inner lining of the uterus grow in atypical places.PDT destroys these cells in a targeted manner without affecting healthy tissues.

Photodynamic therapy is an organ-preserving method of treatment, which is included in the federal standard of medical care (see the order of the Ministry of Health of Russia dated 01.11.2012 N 572n (as amended on 11.06.2015) “On approval of the Procedure for providing medical care in the field of obstetrics and gynecology “).

3. Precancerous state of the endometrium – complex endometrial hyperplasia, adenomatous endometrial hyperplasia, atypical endometrial hyperplasia – can also be treated by PDT.To date, I have successfully treated 2 patients with this pathology.

In cases where hyperplasia is predominantly of a viral nature, PDT treatment can eliminate the cause of the disease. In the treatment of pathologies of the cervix uteri, complete destruction of the human papillomavirus after one PDT session is confirmed in 94% of patients, and in 100% of patients after the second PDT session.

4. Precancerous conditions and oncological formations in the cervix. Grade 3 dysplasia, cervical in situ cancer and even microinvasive cancer can be completely cured with photodynamic therapy in 1 or 2 sessions.

The PDT method eliminates not only the disease itself, but also its cause – the human papillomavirus.

Therefore, correctly and fully performed photodynamic therapy is the only method that ensures lifelong recovery and minimal risk of recurrence (reinfection is possible only in case of re-infection with HPV).

There is one more good news. Previously, a combination of age and multiple gynecological diagnoses was a compelling reason for removing an organ.For example, a combination of condylomas of the cervix and uterine fibroids, or dysplasia of the cervix with adenomyosis against the background of the performed generic function.

To justify the removal of an organ, the surgeon usually does not give rational arguments, but refers to his own experience or an established opinion. But today (even if the attending physician tells you otherwise) the combination of several diagnoses is no longer a direct indication for the removal of the uterus. Modern medicine considers each diagnosis as an independent one, and for each treatment tactics is determined individually.

For example, dysplasia and adenomyosis regress after photodynamic therapy. And the presence of multiple fibroids is not a reason for oncological alertness. Numerous observations of recent years show that fibroids have nothing to do with cancer, do not degenerate into a cancerous tumor, and are not even a risk factor.

In surgery, there is a concept of the risks of treatment. The job of a good doctor is to minimize risks. When the doctor determines the tactics of treatment, he is obliged to evaluate the indications, to measure the possible negative consequences of different methods of treatment, and to choose the most gentle and effective one.

By law, doctors must inform about all possible treatments, but in practice this does not happen. Therefore, against the background of the surgeon’s urgent recommendations for organ removal, I strongly advise you to consult several specialists or write to me to assess the possibility of performing organ-preserving treatment that is right for you.

Unfortunately, not all diseases of the uterus are treated with minimally invasive and therapeutic methods, and in some cases it is still better to remove the uterus.Such indications for removal are called absolute – that is, they do not require discussion.

1. Uterine fibroids with necrotic changes in the node. Preservation of an organ with such a diagnosis is life threatening.

2. Prolonged uterine bleeding that cannot be stopped by any other means. This condition is fraught with the loss of a large volume of blood and is a serious life-threatening condition.

3. The combination of large uterine fibroids and cicatricial deformity of the cervix.

4. Prolapse of the uterus.

5. Cancer, starting from stage I.

6. Giant sizes of tumors.

Depending on the indications, operations on the uterus are performed by different methods and in different volumes. First, we will get acquainted with the types of surgical intervention. Then I will dwell on the consequences that, to one degree or another, every woman will experience after the removal of this organ.

Removal of the uterus without ovaries.Consequences of extirpation of the uterus without appendages

The concept of adhesions

Adhesions are additional tissue, a feature of which is the sticky fibrin secreted by it. Because of this, this tissue sticks together the organs. This is due to the protective reaction of the body, that is, the growth of adhesions is necessary to maintain the diseased organ or tissues affected by the inflammatory process.

Connective tissue can look different. Namely, in the form of a film, scar, threads.These forms of tissue appear after strip surgery or after minimally invasive interventions.

The formation of adhesions after removal of the uterus is a frequent occurrence, since the process of wound healing is accompanied by the formation of a connective scar. The space that has formed begins to overgrow. The main reason for the appearance of the adhesive process is an individual feature of the organism, in which the enzyme responsible for the resorption of fibrin deposits is not produced in it.

The causal factors of this pathological condition are:

• Additional trauma to adjacent anatomical structures.
• If during a surgical operation the doctor left instruments, napkins, tampons, etc. in the abdominal cavity.
• Infection during the operation, that is, the use of improperly processed instruments, or irregularities in dressings in the postoperative period.
• The occurrence of such complications after surgery as internal bleeding.
• Activation of the inflammatory process.

In addition, the formation of adhesions is influenced by the incision during the operation, namely, the correctness of its execution.The duration of the operation itself is also important.

Pay attention! Medical practice shows that strains after removal of the uterus appear in women who are too thin.

Adhesions begin to form from an accumulation of inflammatory fluid or blood that did not dissolve after surgery. Moreover, their formation begins already from 7-21 days. The exudate gradually thickens until this time and begins to be replaced by connective tissue. After 30 days, blood capillaries and nerve fibers are formed in it.

Symptoms and signs

In most cases, there is no evidence of adhesions. Symptoms appear even when the situation becomes more complicated.

The main symptoms are intestinal dysfunction. Namely, intestinal obstruction, which is manifested by a pathologically rare defecation or a complete cessation of stool discharge. Constipation and flatulence are also observed.

In addition, there will be the following symptoms:

• general malaise and hypotension;
• pain in the lower abdomen;
• in the future, the patient’s condition is complicated by frequent bouts of nausea and vomiting;
• soreness of the postoperative suture;
• the postoperative suture becomes inflamed – it melts bright red, edematous;
• sometimes there is a fever;
• pain after intercourse.

Diagnostics

Diagnosis of the adhesions is difficult, since an exact verdict can be set only after laparoscopy or a full-fledged abdominal operation. But the doctor can suspect the presence of adhesions after the following diagnostic methods:

• Laboratory blood tests. With their help, the presence of an inflammatory process is determined and the activity of fibrinolysis can be assessed.
• Ultrasound of the abdomen and pelvis allows you to assess the location of the organs.The doctor may assume that there is a lesion with connective tissue, since the organs will be incorrectly located.
• Diagnostic laparoscopy is a minimally invasive method that allows you to fully visualize organs and other structures using a special manipulator.

When adhesions form after surgery to remove the uterus, an X-ray examination of the intestine is sometimes prescribed, especially if there is a complex of symptoms of organ dysfunction. In this case, contrast agents are used.As a result, it is clear how narrowed the intestinal lumen and what degree of intestinal patency.

Adhesion hazard

Adhesions themselves are a postoperative complication. They can cause serious consequences, since the proliferation of connective tissue contributes to the disruption of the normal functioning of organs.

Dangerous complications are:

• acute intestinal obstruction;
• necrotic intestinal lesion;
• peritonitis.

Treatment

When a woman’s uterus is removed, she is prescribed preventive therapy. It includes a list of medications that also prevent the formation of adhesions. These include anti-inflammatory drugs, antibiotics and enzyme preparations,

Physiotherapy has also proven effective. They are used both for the prevention of the manifestation of adhesions, and already in their presence.

Physiotherapy

Electrophoresis is one of the physiotherapy procedures that can destroy postoperative adhesions.And also has a pronounced effect, that is, the symptoms are relieved. Usually 10-12 procedures are prescribed. Electrophoresis is used in conjunction with pain medications.

In addition, paraffin and ozokerite applications are used. Today, laser therapy and magnetotherapy are popular methods of treatment.

Fibrinolytic agents are very effective in the presence of adhesions, since they contain enzymes that can dissolve fibrin. These include:

• Urokinase – breaks down blood clots by dissolving them.
• Fibrinolysis – this substance is capable of dissolving fibrin.
• Chemotrypsin is an agent that helps to thin the viscous exudate and thickened blood. The active substance breaks down fibrous deposits and necrotic tissue.
• Hyaluronidase (Lidase) – this drug contains hyaluronic acid in its composition. The action is aimed at softening the scars, as well as for the treatment of hematomas.
• Streptokinase – this agent is able to dissolve blood clots, or rather dissolve fibrin in blood clots.
• Trypsin.

Laparoscopy

Laparoscopy is a surgical treatment related to minimally invasive interventions. This method consists in making several small incisions by the doctor through which instruments and a manipulator are inserted. During the operation, the adhesions are dissected and the vessels are cauterized. Also, the doctor must remove the synechiae. This is done using a laser, aquadissection, or electrosurgery.

The positive factor of such treatment is the minimum list of complications, which, moreover, are extremely rare.Also, rehabilitation after laparoscopy does not last long. The very next day after this operation, a woman can get up. The recovery period is no longer than a few days.

A lane surgery to remove adhesions is called a laparotomy.

Prophylaxis

The main prevention of adhesions is a correctly performed surgical treatment, without any disturbances, since adhesions are formed after operations. Also, the manifestation of strands can be affected by incorrect rehabilitation methods.How to avoid adhesions? Doctors recommend after the intervention to remove the uterus:

• Follow the diet.
• Properly care for the postoperative suture so that there is no infectious contamination of the wound.
• Avoid excessive physical exertion, but you need to move more.

If all these rules are followed, the risk of adhesion is reduced.

Conclusion

The adhesion process after surgery is quite dangerous.Therefore, if you experience any symptoms, you should consult a doctor. After all, this pathological condition can lead to dangerous consequences.

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Ovarian adhesions are not uncommon. Often, growths appear after operations on the appendages and uterus, surgical abortion and other types of interventions.Adhesions lead to intense pain in the lower abdomen and disruption of the usual menstrual cycle, deteriorating the health of the woman as a whole. If the disease is not treated, a woman may not realize her reproductive function.

Whether the cervix is ​​retained or removed when the uterus is removed depends on the condition of the cervix and the risks associated with its preservation.

If the cervix is ​​left, this is the most favorable situation possible.

On the one hand, due to the preserved ovaries, the hormonal system continues to function in a more or less normal mode.But why leave the cervix when the uterus is removed? Preserving the cervix allows you to maintain the length of the vagina, and after recovery, the woman will be able to lead a full sex life.

Removal of the uterus without appendages, but with the cervix, is a more traumatic operation.

By leaving the ovaries, the surgeon enables the woman to maintain normal hormonal levels. If the operation is performed at a young age, the ovaries can avoid menopause and all associated health consequences.

But even after removal of the uterus without appendages, the anatomical relationship of organs is disturbed. As a result, their function is disrupted.

In addition, complete removal of the uterus, even with preservation of the ovaries, leads to a shortening of the vagina. In many cases, this is not critical for sexual activity. But the anatomy of the organ is different for everyone, and not all women manage to adapt.

This is the most traumatic operation that takes a long time to recover.

It needs serious hormonal correction and usually causes all the most serious consequences, especially if it is performed at the age of 40-50 years – that is, before the onset of natural menopause.

I will describe in more detail the most common consequences of removing the uterus below. The most unpleasant thing is that all these consequences are irreversible and practically not amenable to correction.

This is a fairly common complication in cases where the ovaries are preserved after removal of the uterus.This is how the negative influence of the operation itself is manifested.

To understand the nature of a cyst, you must first understand how the ovaries work.

In fact, a cyst is a natural process that occurs every month in the ovary under the influence of hormones and is called a follicular cyst. If the egg is not fertilized, the cyst bursts and menstruation begins.

Now let’s see what happens to the ovaries after the removal of the uterus.

The uterus itself does not produce hormones.And many surgeons assure that after its removal the hormonal background will not change. But they forget to say how closely the uterus is connected to other organs. When the ovaries are separated from the uterus, the surgeon inevitably disrupts the blood supply and injures them. As a result, the work of the ovaries is disrupted, their hormonal activity decreases.

Consequence 1. Serious hormonal disorders

Until now, convincing patients to agree to the operation, surgeons utter the same monologue – supposedly, the uterus is needed only for the birth of children, supposedly it does not produce hormones, and there is almost no way to remove it is reflected in the quality of life.

It remains a mystery to me on what basis these surgeons believe that removing the uterus will not affect the patient’s quality of life in any way. Moreover, many surgeons are really convinced that after 50 years, a woman does not need organs such as the uterus and ovaries.

Meanwhile, a series of recent scientific studies in this area say the opposite. Even if the ovaries are preserved, removal of the uterus is an operation with a high risk of endocrine disorders.

The reason is simple.The uterus is connected to the ovaries and tubes by a system of ligaments, nerve fibers and blood vessels. Any operation on the uterus leads to a serious violation of the blood supply to the ovaries, up to partial necrosis. Needless to say, hormone production is disrupted in literally choking ovaries.

Hormonal disruptions are manifested by a whole string of unpleasant symptoms, the most harmless of which is a decrease in libido.

In the overwhelming majority of cases, the ovaries are not able to completely restore or compensate for the normal blood supply.Accordingly, the hormonal balance of the female body is not restored either.

Consequence 5. Sex after removal of the uterus

For women who have undergone vaginal removal of the uterus, sexual rest must be observed for at least 2 months until the internal sutures heal. In all other cases, sex can be engaged in 1-1.5 months after the operation.

Sex life after removal of the uterus undergoes changes.

In general, women are worried about vaginal dryness, burning after intercourse, discomfort, painful sensations.This is due to a drop in estrogen levels, due to which the genital mucosa becomes thinner, and begins to produce less lubricant. Hormonal imbalance reduces libido, interest in sex life decreases.

• Removal of the uterus with appendages is most reflected in the intimate side of life, since the absence of female hormones leads to frigidity.
• Removing the body of the uterus has little effect on intimate life. There may be vaginal dryness, decreased libido.
• Removing the uterus with the cervix shortens the vagina, making it difficult to have sex after surgery.

Consequence 6. Orgasm after removal of the uterus

Does the woman have an orgasm after removal of the uterus?

On the one hand, all sensitive points – the G-spot and the clitoris – are preserved, and theoretically a woman can still experience an orgasm even after the organ is removed.

But in reality, not every woman gets an orgasm after surgery.

So, when the ovaries are removed, the content of sex hormones in the body drops sharply, and many develop sexual coldness. A decrease in the production of sex hormones occurs even when the ovaries are preserved – for many reasons, after the operation, their activity is disrupted.

The best prognosis for orgasms for those who still have a cervix.

Consequences after removal of the uterus and cervix are manifested in the shortening of the vagina by about a third. Full sexual intercourse often becomes impossible.Research carried out in this area has shown that the cervix is ​​of great importance in achieving vaginal orgasms, and when the cervix is ​​removed, it becomes extremely difficult to achieve.

Consequence 7. Pain after removal of the uterus

Pain is one of the main complaints after surgery.

1. In the postoperative period, pain in the lower abdomen may indicate a problem in the suture area or inflammation. In the first case, the stomach hurts along the seam. In the second case, high temperature is added to the main symptom.

2. If the lower abdomen hurts and there is swelling, you can suspect a hernia – a defect through which the peritoneum and intestinal loops go under the skin.

3. Severe pain after surgery to remove the uterus, high fever, poor health indicate pelvioperitonitis, hematoma or bleeding. Reoperation may be required to resolve the situation.

4. Heart pains indicate the possibility of developing cardiovascular diseases.

A large Swedish study of 180,000 women showed that hysterectomy significantly increases the risk of cardiovascular disease, coronary artery disease and stroke. Removing the ovaries further aggravates the situation.

5. If you are concerned about leg swelling, an increase in local skin temperature – you need to exclude thrombophlebitis of the veins of the small pelvis or lower extremities.

6. Pain in the back, lower back, right side or left can be a symptom of adhesive disease, cysts on the ovary and much more – it is better to consult a doctor.

Consequence 8. Descent after removal of the uterus

After removal of the uterus, the anatomical arrangement of organs is disturbed, muscles, nerves and blood vessels are injured, the blood supply to the pelvic region is disturbed. The framework that supports the organs in a certain position ceases to fulfill its functions.

All this leads to displacement and prolapse of internal organs – primarily, the intestines and bladder. An extensive adhesion process exacerbates the problem.

This is manifested by numerous growing problems from the intestines and urinary incontinence during exercise, coughing.

Consequence 9. Prolapse after removal of the uterus

The same mechanisms cause the so-called prolapse of the genitals – prolapse of the vaginal walls and even their prolapse.

If in the postoperative period a woman begins to lift weights without waiting for full recovery, then the situation is aggravated. Intra-abdominal pressure rises, the walls of the vagina are “pushed” outward. Lifting weights for this very reason is contraindicated even for healthy women.

When lowering, the woman has a feeling of a foreign object in the perineum. Disturbed by pain. Sexual life becomes painful.

To reduce the symptoms of prolapse of the vaginal walls after removal of the uterus, special gymnastics is indicated. For example, Kegel exercises. Constipation also increases intra-abdominal pressure, therefore, in order to prevent the process, you will have to learn how to monitor the work of the intestines: bowel movements should be daily, and feces should be soft.