Pelvic Adhesions

Fri, 30 Mar 2018 | Laparoscopic Urology

In the reproductive age female, there is concern regarding adhesion formation and resultant infertility. Adhesions are thought to interfere with ovum pickup by the tubal fimbriae. Although the evidence of external adhesions' contribution to decreased fertility is controversial, it is generally recommended to minimize the extent of damage to the serosal surfaces of both the ovary and fallopian tube in females of reproductive age. The potential decrease in fertility as a result of pelvic adhesions should be discussed with the patient.

Pelvic adhesions may result from previous surgery, inflammatory disorders, pelvic infection, or endometriosis. The pathogenesis involves creating a deperi-tonealized surface. When damage occurs to this surface, the repair process is rapid and essentially in place by eight days. The first process involves primitive mesothe-lial cells that repair serosal defects from the underlying mesenchyme. The second healing process occurs when fibrin deposits are laid down after three days (9). This results in adhesion formation.

There is a long held belief that adhesions cause chronic pelvic pain. Good evidence exists showing that adhesiolysis does not improve chronic pain. In 2003, Swank et al. reported 100 patients with continuous or intermittent abdominal pain thought to be due to adhesions from previous surgery of at least six months' duration (10). These patients were randomized to diagnostic laparoscopy versus diagnostic laparoscopy and lysis of adhesions. The authors found there was significant pain relief and improvement in generalized quality of life in both groups up to a year from surgery. However, there was no difference between groups, concluding that laparoscopic lysis of adhesions is not more beneficial than diagnostic laparoscopy alone. This may not apply to patients with an identifiable pelvic pathology such as endometriosis in which evidence supports resection of the pathology.

TABLE 1 ■ Frequency of Ureteral Injuries After Major Gynecologic Surgery
				No. of	No. of ureteral	No. of injuries	No. of injuries
			No. of	ureteral	injuries/1000	recognized	recognized
Study	Year	Operation	operations	injuries	operations	intraoperatively	postoperatively
Rosen et al.	1996	Open Burch	929	4	4.3	0	4
		colposuspension
Saidi et al.	1996	Major laparoscopic	953	4	4.2	0	4
		surgerya
Harkki-Siren et al.	1998	Laparoscopic	2,741	37	13.5	2	35
		hysterectomy
Liu and Reich	1994	Laparoscopic	518	1	1.9	0	1
		hysterectomy
Stanhope et al.	1991	Major abdominal	2,833	2	0.7	0	2
		surgeryb
Daly and Higgins	1988	Major abdominal	1,093	16	14.6	8	8
		surgeryb
Falk and Bunkin	1954	Adnexal surgery	567	1	1.8	0	1
Harkki-Siren et al.	1998	Total abdominal	43,149	17	0.4	0	17
		hysterectomy
Goodno et al.	1995	Total abdominal	2,469	8	3.2	NE	NE
		hysterectomy
Kunz	1984	Total abdominal	737	3	4.1	1	2
		hysterectomy
Dicker et al.	1982	Total abdominal	1,283	3	2.3	0	3
		hysterectomy
Amirikia and Evans	1979	Total abdominal	4,228	5	1.2	NE	NE
		hysterectomy
Thompson and Benigno	1971	Total abdominal	2,287	9	3.9	NE	NE
		hysterectomy
Falk and Bunkin	1954	Total abdominal	1,114	1	0.9	0	1
		hysterectomy
Holloway	1950	Total abdominal	808	6	7.4	1	6
		hysterectomy
Newell	1939	Total abdominal	944	8	8.5	0	5
		hysterectomy
Harkki-Siren et al.	1998	Subtotal abdominal	10,354	3	0.3	1	2
		hysterectomy
Falk and Bunkin	1954	Subtotal abdominal	1,577	1	0.6	1	0
		hysterectomy
Newell	1989	Subtotal abdominal	2,072	5	2.4	1	2
		hysterectomy
Stanhope et al.	1991	Major vaginal surgery0	2,546	16	6.3	0	16
Harkki-Siren et al.	1998	Vaginal hysterectomy	5,636	1	0.2	0	1
Goodno et al.	1995	Vaginal hysterectomy	1,054	5	4.7	NE	NE
Kudo et al.	1990	Vaginal hysterectomy	9,230	3	0.3	NE	NE
Dicker et al.	1982	Vaginal hysterectomy	568	0	0	0	0
Amirikia and Evans	1979	Vaginal hysterectomy	2,111	2	0.9	NE	NE
Thompson and Benigno	1971	Vaginal hysterectomy	1,533	1	0.7	NE	NE
Falk and Bunkin	1954	Vaginal hysterectomy	1,664	2	1.2	0	2
Copenhauer	1962	Vaginal hysterectomy	1,000	2	2.0	0	2
Edwards and Beebe	1949	Vaginal hysterectomy	570	2	3.5	0	2
Total			107,068	168		15	115
Note: NE = not able to elicit information about whether ureteric injury was diagnosed intraoperatively or postoperatively from the details provided in the report.
aIncluding laparoscopic hysterectomy (with/without adnexectomy), ovarian cystectomy, and ablation of severe (grade 4) endometriosis (6).
bIncluding total abdominal hysterectomy and/or other abdominal gynecologic operations for the treatment or pelvic conditions (5,30).
including vaginal hysterectomy and/or other vaginal operations for the correction of vaginal prolapse.

TABLE2 ■ Frequency of Bladder Injuries After Major Gynecologic Surgery
				No. of	No. of bladder	No. of injuries	No. of injuries
			No. of	bladder	injuries/1000	recognized	recognized
Study	Year	Operation	operations	injuries	operations	intraoperatively	postoperatively
Saidi et al.	1996	Major laparoscopic surgery3	953	11	11.5	8	3
Harkki-Siren et al.	1998	Laparoscopic hysterectomy	2,741	24	8.8	14	10
Ou et al.	1994	Laparoscopic hysterectomy	839	8	9.5	NE	NE
Liu and Reich	1994	Laparoscopic hysterectomy	618	6	11.6	5	1
Harkki-Siren et al.	1996	Total abdominal hysterectomy	43,149	54	1.3	9	45
Kunz	1984	Total abdominal hysterectomy	737	1	1.4	1	0
Dicker et al.	1982	Total abdominal hysterectomy	1,283	4	3.1	4	0
Amirikia and Evans	1979	Total abdominal hysterectomy	4,228	18	4.3	NE	NE
Falk	1967	Total abdominal hysterectomy	1,000	5	5.0	2	3
Graber et al.	1964	Total abdominal hysterectomy	819	16	19.5	11	5
Howkins	1963	Total abdominal hysterectomy	1,000	2	2.0	1	1
Holloway	1950	Total abdominal hysterectomy	808	8	9.9	6	2
Harkki-Siren et al.	1998	Subtotal abdominal hysterectomy	10,854	3	0.3	2	1
Harkki-Siren et al.	1998	Vaginal hysterectomy	5,636	1	0.2	0	1
Kudo et al.	1990	Vaginal hysterectomy	9,230	44	4.8	NE	NE
Dicker et al.	1982	Vaginal hysterectomy	568	9	15.8	8	1
Amirikia and Evans	1979	Vaginal hysterectomy	2,111	4	1.9	NE	NE
Copenhauer	1962	Vaginal hysterectomy	1,000	11	11.0	10	1
Allen and Peterson	1964	Vaginal hysterectomy	2,280	2	0.9	0	2
Total			89,754	231		81	76

Note: NE = not able to elicit information about whether ureteric injury was diagnosed intraoperatively or postoperatively from the details provided in the report. including laparoscopic hysterectomy (with/without adnexectomy), ovarian cystectomy, and ablation of severe (grade 4) endometriosis.

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