Pelvic Adhesions

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.

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.

51 Tips for Dealing with Endometriosis

51 Tips for Dealing with Endometriosis

Do you have Endometriosis? Do you think you do, but aren’t sure? Are you having a hard time learning to cope? 51 Tips for Dealing with Endometriosis can help.

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