Different Views on Adhesion Management

Recently a letter was sent to the Women's Health Forum by a patient who had undergone numerous surgeries in an effort to alleviate her pain due to surgical adhesions. Additionally, I recently had a patient whose case demonstrates a rather typical story for post-surgical adhesions, and her management. These two patient cases I hope you will find informative and "food for thought".

1) Toni is the patient who had undergone numerous prior surgeries, had the pain relieved for a week or so, and then it recurred, again. She is contemplating yet another surgical procedure, followed by several weeks of bed rest in the hope that such an approach will finally prove successful.

My response:

First of all, adhesions are a by product of the body's attempt to heal injured tissue. Surgery is controlled tissue injury!! The healing process begins immediately after the injury. If you cut your finger, it bleeds for a while, and then a clot forms, and if undisturbed, scar tissue permanently seals the injury site. A small cut can be accidentally re-opened within a few days if the injury site is accidentally bumped, but within several more days the scar is strong (i.e. fibrous) enough to remain permanently sealed.

Within the abdomen, raw surfaces resulting from controlled "surgical injury", begin to seal over within hours of the tissue trauma. Initially, the healing tissues are very gelatinous and soft; adjacent structures may become somewhat "stuck" to other structures (e.g. bowel to the abdominal wall). The extent of this soft "attaching" tendency varies from patient to patient, the nature of the surgery, as well as compounding factors such as coincident or subsequent infection. Many areas of tissue injury form no adhesions whereas other areas stick together as if you used glue!! As the repairing process continues with time, the soft gelatinous attachments become more fibrous, less pliable, and very dense and strong (i.e. mature scar or adhesion formation).

Your story is sooooo typical..... "I had adhesion surgery, was free of Pain for a few weeks and now I am worse than ever." This is reflecting IMHO, the maturing and progressive fibrous scarring that is occurring. Further IMHO, the worse thing you can do is to remain quiet, and allow these raw surfaces to further solidify. I encourage movement (side to side, knee chest, walking, as soon as the patient returns from the recovery room) every 15 minutes for the first 1-2 days.

Non-conventionally, I re-laparoscope these severe-adhesion patients in 5 days while any new adhesions are soft and easily wiped away. So far this approach seems to work.

Lastly, would suggest you research well the gyn surgeons available to you. Most gyns who encounter dense adhesions will almost immediately resort to laparotomy, perform a big incision (ie start the adhesion problem over again big-time!!), and then wonder why the patient becomes symptomatic again in weeks??? There are experienced advanced-laparoscopic surgeons out there who rarely have to resort to laparotomy. The key is the experience to qualify as an "advanced laparoscopic" surgeon. You need to query your doctors about these qualifications. Being able to remove an ovarian cyst, or cauterize a little endometriosis is NOT sufficient IMHO

2) Jodie was a 30year old woman with one child. In the preceding 8 years she had undergone several laparoscopies for endometriosis, as well as receiving several courses of Lupron for suppression. Her pelvic pain and tenderness would resolve for a while but then return to the point that she had become a pelvic cripple. Jodie decided to undertake a final procedure that would allow her to get on with her life. She underwent a laparoscopic supracervical hysterectomy, with removal of her one remaining ovary. Endometriosis was encountered, and surgically destroyed. She was discharged the following day, and her pre-operative pelvic pain had totally resolved. Within the week however, Jodie began having excruciating deep pelvic pain, but only with bowel movements. The pain was so severe that she could only cope with bowel elimination if she took a potent pain pill. Jodie was agreeable to waiting several weeks so that the internal healing process would be complete, and hopefully the problem would abate. This did not happen.

My conclusion was that she had formed a post-surgical adhesion(s) in her pelvis and only laparoscopy would be able to prove this suspicion and correct the problem.

Next began a long hassle with her managed care insurance company, who mandated a consultation with a gastroenterologist!! Jodie underwent the mandated tests that demonstrated NOTHING (adhesions are rarely demonstrated on any of these tests). A final laparoscopy was ultimately performed and indeed the suspected adhesions were encountered, taken down, and at last she is 100% pain free.

Adhesion problems can be totally incapacitating, causing continued pain, cramping, bowel disturbance, and tenderness. The most common alternative diagnosis is often irritable bowel syndrome, which affects as many as 20% of the population. The treatment of this disorder is medical. However if this therapy fails, and if the patients has had previous abdominal surgery, IMHO, pelvic/abdominal adhesions need to be strongly considered in the differential diagnosis.