Sticking Together

When injury or inflammation occurs, it is the body’s normal response to heal itself, forming scar tissue to protect and close a wound. While they have a protective function, these types of scar tissue tend to cause surfaces inside the body to adhere to each other.

How adhesions arise

Adhesions are a type of scar tissue that usually occur inside the abdomen. Similar to the way a scab forms over a cut on a finger, the body produces protective tissues when there is trauma to its cells. Adhesions refer to these tissues – deposits of fibrous strands or scar tissue.

In the abdominal space, organs such as the intestine and uterus or fallopian tubes may move against the forming scab, causing scar tissue to stretch like cobwebs and adhere these organs together. This can cause problems because the naturally mobile organs can become stuck together.

Adhesions are often formed as part of the normal wound healing process that occurs in response to an injury to the tissues of the body. Adhesions can occur almost anywhere in the body, including the joints, such as the shoulder and the eyes. Most commonly, they occur in the lining of the abdomen and pelvis (called the peritoneum). Usually, adhesions in the peritoneum can occur between the uterus, fallopian tubes, ovaries, bowel (both small and large intestines), omentum (fat covering the intestines) and the abdominal wall.

Damage in the female pelvis is most commonly caused by a reaction to infections (eg. salpingitis, pelvic infection and appendicitis), endometriosis, inflammatory disease and trauma. A common cause of trauma is abdominal or pelvic surgery. Adhesions seen during surgery are an indication that recurrence of adhesions is more likely. Surgery using a laparoscope is less likely to cause adhesions than open surgery mainly because less tissue is cut to reach the operating site and under high magnification dissection is more precise and less traumatic to tissue.

Sticky complications

Adhesions do not always lead to problems but when they do cause difficulties, the conditions may be severe. Adhesions may become thicker or tighter over time and can cause formation of bands around which an organ or body part can twist itself (eg. torsion of intestines causing obstruction, twisting of ovarian cyst causing strangulation). The ovary or fallopian tubes can be pulled out of position and movement of sperm and eggs can be affected.

This can cause a range of problems such as:

  • Pain if they restrict the movement of mobile organs such as the bowel or ovaries in the abdomen or pelvic cavity; or if nerve endings become entrapped within developing adhesions.
  • Bowel obstruction due to herniation or when dense adhesions narrow the bowel (a condition known as a stricture). To reduce the risk of adhesion formation, adhesion barriers are often used after operations like hysterectomy, myomectomy and cystectomy.
  • Bladder problems such as pain and frequency can result when adhesions reduce the capacity and proper emptying of the bladder. The condition can be mistaken for cystitis.
  • Dyspareunia or pain during sexual intercourse result from adhesions that ‘stick down’ the ovaries, especially to the uterus and large intestine.
  • Infertility if adhesions displace the ovaries from their normal position, or if they block the fallopian tubes.

Typically, adhesions show no symptoms and go undiagnosed unless they cause pain by pulling nerves. They are usually detected in the course of investigation and usually only during an operation, laparotomy or laparoscopy, or during a hysteroscopy in the case of intrauterine adhesions.

In some cases, a sign of adhesion is moderate to severe endometriosis (severe menstrual bleeding and cramps). In other scenarios, an adhesion may be detected during a vaginal examination when it is found that the uterus is in fixed retroversion (stuck in an abnormal position instead of being mobile). If the adhesions cause a blockage of the intestines, symptoms may include bloating or swelling of the belly, constipation, nausea and vomiting, inability to pass gas and tummy pain or cramps.

Detecting adhesions

If an adhesion is suspected, one way to confirm diagnosis is a surgical procedure such as laparoscopy (where a long thin tube with a camera is inserted through a small hole into the stomach to visualise the organs). The adhesion can be released during the same surgery. Another way would be to do blood tests, X-rays, and CT scans to determine the extent of an adhesionrelated problem. In women, a hysterosalpingography may be done. This is a special X-ray that uses dye to look at the uterus and fallopian tubes.

It is important to understand that no indirect imaging methods can ‘show’ (demonstrate to) you the adhesions. At best the tests show the displacement of organs by presumed adhesions or distortion of the anatomy attributable to adhesions.

The only method to accurately ‘see’ adhesions is by doing a diagnostic laparoscopy and if the adhesions are detected and deemed treatable, proceed to convert to operative laparoscopy to lyse the adhesions, hence the term adhesiolysis.