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.
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. |
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.

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