Adhesions

Adhesions are detectable only during laparoscopy.

Adhesions are a major cause of infertility and pain in women but are extremely difficult to detect by conventional imaging methods.

Ultrasound, computerised tomograms, and magnetic resonance imaging (MRI) all give only indirect evidence of the presence of adhesions. Only direct visualisation of adhesions during laparoscopy can confirm the presence and determine the extent of adhesions.

Adhesions are bands of tissue between 2 surfaces inside the body. They are scar tissue formed in the healing process after trauma or damaging events like infection or surgery. Scar tissue on the skin are hard, as in keloids, Adhesions are scar tissues stretched out between surfaces and look like cobwebs.

Most times they are harmless but located in the wrong places can cause twisting of intestines as in intestinal obstruction, closure of tubular structures like the fallopian tube, and cover the ovaries preventing proper release or movement of eggs resulting in infertility.

Treatment

Surgery to excise the adhesions may "sure" some problems but it is important to note that repeated surgery tends to result in more adhesions. To seek treatment via surgery consult Singapore Gynaecologist, Dr Yap Lip Kee.

Type of Adhesions

The videos below show adhesions in various locations and methods of dealing with them.

Omental Adhesions

After previous surgery the omentum often gets stuck to the abdominal wall making subsequent surgery more difficult. The video shows use of scissors for lysis of adhesions. The omentum is a large fold of peritoneum that hangs down from the stomach and the transverse colon. The fat on the omentum has a protective function and serves to allow smooth movement of bowel over it. When there is an injury as in surgery it may become adherent (stuck) to raw surfaces during the healing process. These can be dense when a large area of healing was involved.

Filmy adhesions between uterus and omentum can accour when damage is less severe e.g. after an infection treated in theearly stages

Pelvic Adhesions

When infections are not treated early enough they can cause widespread damage in the pelvis as in the video where dense adhesions have formed between ovaries and posterior wall of uterus. Both fallopian tubes are also stuck to the uterus

Despite the extensive damage the tubes are still patent though not necessarily functioning well. Passage of blue dye put through the cervix show that tubes are not blocked.

These adhesions between the ovary and the tubes may cause blockage of the tubes. Cutting the adhesions sets the ovary free form its abnormal positions, stuck to the side wall. It should be able to move freely.

Fine adhesions over the ovaries can prevent proper release of egg or cause entrapment preventing the descent of the egg through the fallopian tube even though the tubes not blocked.

Fine adhesions between ovary and side abdomen causing the ovary to lie in the wrong place, less efficient for entry of the egg into the fallopian tube after it is released from the ovary.

Adhesions causing the left ovary to be stuck to the recto-sigmoid (large bowel near rectum)

Dense adhesions between utero-vesicle fold (layer over the bladder) and uterus causing a change in the position of the womb (uterus)

Dense adhesion between the uterus recto-sigmoid (large intestine) can cause the uterus to be positioned too far backward (retroverted). Release often give pain relief.

Adhesions causing the ovary to be stuck to the pelvis side wall. Note that eggs may be released but appear unlikely to take proper route into the uterus. In this case the adhesions are due to endometriosis. The presence of the endometriotic cyst probably caused irritation of the ovary surface causing a reaction which resulted in the ovary being stuck by the scar tissue (in the form of adhesions) to the side wall.

Peri-hepatic adhesions

Adhesions often occur around the liver following infections like chlamydia. They are usually asymptomatic (do not cause problems) hence best left alone. Some are fine, filmy adhesions...

.. while others can be thick (dense)

Adhesions Prevention

Generally the best eay to prevent adhesion formation during surgery is to handle tissue in a gentle manner. Amongst products used to reduce adhesion formation the best appears to be an adhesion barrier called Interceed. Even this is no guarantee against adhesion formation and reformation. Usage is illustrated in this video.