Adhesions commonly form in the abdominal-pelvic cavity as a result of inflammation, injury or following surgery – as part of the body's completely natural and normal healing process. 

Usually they occur as part of the healing that takes place after surgery, particularly abdominal surgery. 

Adhesions can also form after inflammation in the abdomen or pelvis. 

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 2 surfaces. 

• During the body's reaction that leads to an adhesion, chemicals called inflammatory mediators and histamines are released from the blood (more specifically the blood's mast cells and leukocytes). 
  
• Capillaries dilate. This allows leukocytes, red blood cells and platelets to concentrate at the injury site in a bundle called a fibrinous exudate. 
  
• A variety of other factors are at play in the system such as as prostaglandins, bradykinin, chemotactic agents, lymphokines, seretonin and transforming growth factor. 
  
• At this point in time fibrinolysis may clear the fibrinousexudate. 
  
• In order for this to occur, plasminogen must be converted to plasmin by tissue plasminogen activator (t-PA). There is constant interplay between the t-PA and plasminogen-activator inhibitors. 
  
• Unfortunately surgical trauma normally decreases t-PA activity while simultaneously increasing plasminogen activator inhibitors. 
  
• If this occurs, the fibrinous exudate is transformed into an organized adhesion where fibers of collagen are deposited. 
  
• Blood vessels begin to form, which leads to an adhesion.

• Causes of adhesions

  What are the causes of adhesions in gynecological and abdominal surgery?

  Adhesions may form as the result of the following common gynaecologic procedures: 

  
  Ovarian Surgery:
  The ovary is the most common site for adhesions to form, usually resulting from surgery to remove ovarian cysts. 

  Surgical Treatment of Endometriosis:
  Endometriosis is a disease in which patches of endometrial tissue – the mucous membrane that lines the inside of the uterus – become implanted outside the uterus. Endometriosis often occurs in the pelvis and abdomen and can be associated with severe inflammation and dense adhesions. The abnormal tissue is removed through surgery. 

  Myomectomy
  Myomectomy is the removal of fibroids from the uterus. Adhesion formation at the incision line on the uterus is a common complication of the procedure. 

  Adhesiolysis
  Adhesiolysis is the removal or surgical separation of adhesions. Ironically, the removal of adhesions can aggravate the healing process, thereby leading to the formation of new adhesions. 

  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 lead to the formation of new adhesions. 

  Adhesions also are a common occurrence in women who suffer from pelvic inflammatory disease (PID) and sexually transmitted diseases. 

  Factors that contribute to the cause of adhesions include the following:

  Trauma:
  The healing process from surgery is a major contributor to adhesion formation. 

  Ischemia:
  During surgery, blood flow is often disrupted as a result of tissue cutting, blood clotting or tying of stitches. This may result in ischemia, or reduction of blood flow to the tissues, therefore contributing to adhesion formation. 

  Foreign Bodies: 
  Foreign bodies include stitches, lint from sponges or talc from surgical gloves. Foreign bodies can cause an inflammatory reaction in the body and can trigger adhesion formation. 

  Inflammation: 
  Endometriosis and PID can cause inflammation, which can result in adhesion formation. 

  Adhesions following abdominal surgery

  Abdominal surgeries that could lead to adhesions include 
  

  • colectomy,
    
  • hernia repair
    
  • adhesiolysis for bowel obstruction.
    
  • Appendectomy
    
  • Cholecystectomy
    
  • Cancer surgery
    
  • Liver and spleen surgery

  Adhesions have been documented to occur in up to 94% of patients after major abdominal surgery

   

The word adhere literally means to stick or to bind together. 

When tissue that is normally not connected grows together, it is called an adhesion. It is also commonly referred to as scar tissue. 

Adhesions are fibrous tissues (scar tissue) that cause organs within the body to adhere to other internal organs that are not normally connected. 

Adhesions may appear as thin sheets of tissue similar to plastic wrap or as thick fibrous bands. 

Adhesions may involve the female reproductive organs (ovaries, Fallopian tubes) can and do cause infertility, dyspareunia (painful intercourse) and debilitating pelvic pain. Adhesions involving the bowel can cause bowel obstruction or blockage. 

Adhesions may form elsewhere such as around the heart, spine and in the hand where they lead to other problems. 

How common are adhesions?

How common is the problem of adhesions?

The rate of adhesion formation after surgery is surprising given the relative lack of knowledge about adhesions among doctors and patients alike. 

Adhesions have been shown to develop in up to 93% of surgical patients. 

This number increased in patients with major and multiple procedures respectively. 

Similarly, some studies found that 93% of patients who had undergone at least one previous abdominal operation had adhesions, compared with only 10.4% of patients who had never had a previous abdominal operation. 

The incidence of adhesions has increased with the rise in gynaecological procedures. 

It has been shown that between 60 to 90 % of women suffer post operative adhesions following major gynaecological surgery. 

 

Types of adhesions

What are the different types of adhesions?

The tissue develops when the body's repair mechanisms respond to any tissue disturbance, such as surgery, infection, trauma, or radiation. 

Although adhesions can occur anywhere, the most common locations are within the abdomen, the pelvis, and the heart. 

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. 

   

  Adhesions between anterior uterine wall

   

  

  Adhesions between uterus ,adnexa and bowel posteriorly

  

  
  

• 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 her fallopian tubes into her uterus for reproduction. 
  
• Tubal adhesions can lead to infertility and increased incidence of ectopic pregnancy in which a fetus develops in the tube.

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 10.4% of people who have never had surgery. 
  
• Most adhesions are painless and do not cause complications. 
  
• However, adhesions cause 60%-70% of small bowel obstructions in adults and are believed to contribute to the development of chronic pelvic pain. 

   

  Bowel adhesions

   

  

  

  
  

• 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.

De novo adhesions

• De novo are new adhesions that may form at a site of direct surgical trauma such as an incision. 
  
• They may also develop at locations away from the site of surgery, for example, around the adnexa at the time of a cesarean section. 
  
• Adhesions may also reform following adhesiolysis or adhesiectomy. 

   

  

Three broad types of adhesions exist, but the underlying pathophysiology is similar for each: 

• Filmsy
  
• Vascular
  
• Cohesive
•  

What is the impact of adhesions?

What is the impact of adhesions on patients and surgeons?

The Impact of Adhesions on Patients:

 

• Adhesive Disease accounts for 49-74% of small bowel obstructions. 
  
• Adhesive Disease accounts for 15-20% of infertility cases. 
  
• Adhesive Disease accounts for 20-50% of chronic pelvic pain cases. 
  
• Reduced quality of life. 
  
• Loss of work days and productivity 
  
• Increased risk, complexity and complications during subsequent surgery. 
  
• One study showed a 19% rate of adhesion-related bowel perforation during subsequent/secondary operations. 
  
• Bowel perforations occur even more frequently (33%) during surgery for SBO. 
  
• Patients with adhesion-related perforations had significantly higher postoperative complications (leaks, wound infections, hemorrhages and length of stay).

The Impact of Adhesions on Surgeons:

• Increased reoperative times 
  
• Increased risk of enterotomy 
  
• Increased level of surgical complexity
•