The Facts

When a woman undergoes any type of gynecologic or abdominal surgery, she has a very high risk of developing post-surgical adhesions. Adhesions occur when bands of scar tissue in the abdominal cavity get “stuck” to pelvic or abdominal organs, thus restricting motion. Adhesions that form after surgery in the pelvic area are often the cause of post-operative pelvic pain, small bowel obstruction, and even infertility.

The risk of adhesions ranges from 67% to 93% after general surgical abdominal operations (like appendectomy and gall bladder surgery) and up to as much as 97% after gynecologic surgery requiring an abdominal incision, such as hysterectomy or a caesarean.¹

Adhesions are also a costly medical problem. A recent study found that in addition to the emotional cost to the patient, the cumulative year on year direct costs to the NHS of adhesion related readmissions due to lower abdominal surgery are estimated to be over £569 million for a 10 year period.^2,3

Despite even the best surgical techniques, post-surgical adhesions form in the majority of patients undergoing gynecologic pelvic surgery and it is impossible to predict who will develop them or where they will occur.

What are Adhesions?

All of the abdominal and pelvic organs, except the ovaries, are wrapped in the peritoneum. When the peritoneum is traumatized during surgery or in some other way, the site of the trauma becomes inflamed. The inflammation contributes to adhesion formation by encouraging the development of fibrous bands of a fibrin matrix.

Normally, these fibrin bands eventually dissolve through fibrinolysis and the traumatized site continues to heal. But sometimes the nature of the surgery results in decreased blood flow to these areas, which can suppress fibrinolysis. If the fibrin bands do not dissolve, they may develop into adhesions that grow to connect or bind together pelvic organs or tissues that are normally separate. Adhesions are more likely to form between broad ligaments, ovaries, sigmoid colon and or the posterior surfaces of the vagina and cervix.

What causes adhesions?

Endometriosis
Endometriosis is a condition where patches of endometrial-like tissue attach to the surfaces of other organs in the pelvis (such as the ovaries and fallopian tubes) and in the abdominal cavity. Endometriosis can grow with hormonal stimulation causing pain, inflammation and scar tissue, and may also cause infertility.

Pelvic Surgery
Most types of pelvic or abdominal surgeries can lead to the formation of adhesions. These include those done by laparoscopy or laparotomy, which involves a traditional incision in the abdomen.

Adhesions can form on any surface in the pelvis and abdomen after surgery. Some organs, though, are more likely than others to develop adhesions. Common gynecologic procedures associated with adhesion formation include:

• Hysterectomy: Adhesions that form after this procedure may attach to the small intestine, causing pelvic pain, constipation, and sometimes a more serious complication - small bowel obstruction (blockage of the intestine that limits or stops passage of its contents). Bowel obstruction may occur soon after surgery or develop many years later.
• Dilaton and curettage (D&C): Adhesions may form after a dilation and curettage in response to the trauma inflicted on the uterine wall.
• Caesarean section: Adhesions may also form after a birth performed by caesarean section. These adhesions typically do not cause pain. They can sometimes make subsequent caesarean sections more difficult, however, because the physician must cut through these adhesions to get to the uterus and the baby, which can increase the length of the procedure and the amount of time the mother and baby are under anesthesia. Although all gynecologic and abdominal surgeries can cause adhesions, caesarean sections, particularly repeat caesarean sections carry a very high risk. One study found that women having their third or more caesarean section were almost twice as likely to experience dense adhesions when compared to those who had undergoing their second (46.1 percent vs. 25.6 percent). Both groups, however, experienced a significant rate of adhesions.
• Ovarian surgery: Ovarian surgery is often performed to remove ovarian cysts. The ovary is one of the most common sites where adhesions form. Adhesion formation after surgery can lead to pelvic pain, pain during intercourse, and infertility.
• Endometriosis: Endometriosis is a disease in which patches of endometrial tissue becomes implanted outside the uterus - usually on the ovaries, bladder or fallopian tubes. This condition can be associated with dense adhesions and infertility.
• Myomectomy: Adhesion formation where the incision is made on the uterus. These adhesions can also affect the ovaries and fallopian tubes, potentially causing infertility and pelvic pain.
• Reconstructive tubal surgery: The repair of blocked fallopian tubes is a delicate procedure that often includes the removal of existing adhesions. Unfortunately, the surgery itself can also lead to the formation of new adhesions and the complications they can cause, such as pelvic pain and infertility.

Illustration of Adhesions

Download the Adhesion Pelvic Pain Fact Sheet.

Symptoms

Symptoms of Adhesions
While most adhesions do not cause trouble, some adhesions can lead to a variety of potentially serious complications including:

• Pelvic pain: Adhesions are a common cause of pelvic pain - an estimated 38% of women suffering from pelvic pain have adhesions. Adhesions cause pelvic pain because they bind normally separate organs and tissues together, essentially "tying them down" so that the stretching and pulling of everyday movements can irritate nearby nerves.
• Pain during intercourse: Adhesions can also cause pain during intercourse.
• Infertility: Adhesions that form as a result of certain types of gynaecologic surgery, especially tubal surgeries and surgeries to remove fibroids are a common cause of infertility. Adhesions can occur between the ovaries, fallopian tubes or pelvic walls thus blocking the passage of the egg. Some experts suspect that pelvic adhesions may be responsible for up to 40 percent of infertility.
• Bowel obstruction: Adhesion formation involving the bowel is particularly common following a hysterectomy. While these adhesions don't normally result in any problems, there is one serious problem that can develop. This problem is called intestinal or bowel obstruction (blockage of the intestine that limits or stops passage of its contents) and it can occur a few days or many years after surgery. Symptoms of bowel obstruction may include pain, nausea, and vomiting.

Treatment Options

There are many adhesion prevention solutions available, aimed at reducing the prevalence and extent of adhesions post procedure. ETHICON™ Women's Health & Urology UK offer the following two adhesion prevention products, which are listed on the right hand side at the top of this page.

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References