Adhesion & scar tissue surgery
What are adhesions & scar tissue?
Types of scar tissue
There are five main types of scar tissue:
Examples of scar tissue and adhesions
Scar tissue formed at the forchette resulting from recurrent tears during sexual intercourse.
Endometriotic deposits in the Pouch of Douglas beginning to form scar tissue on the peritoneum.
Scar tissue Hunners ulcer) forming on the bladder epithelium as a result of interstitial cystitis.
Small bowel stuck with fine adhesions to the anterior abdominal wall.
Scar tissue and adhesions resulting from endometriosis distorting the anatomy of the Pouch of Douglas.
Complete obliteration of the Pouch of Douglas by adhesions between the posterior aspect of the uterus and bowel.
Omentum, adhered to the anterior abdominal wall, about to be divided.
The right ovary is fixed to the right ovarian fossa by filmy adhesions between right utero-sacral ligament and ovary.
Scar tissue on the perineum resulting from lichen sclerosus.
A keloid scar forming in a Pfannensteil (lower transverse abdominal) incision.
A close up of the keloid scar. Such scar tissue is more likely when interrupted sutures are used instead of subcuticular sutures.
Adhesions of large bowel to the vaginal vault and left abdomino-pelvic sidewall.
The principle of adhesion & scar tissue surgery
The restoration of normal anatomy, where the abnormal anatomy noted is thought, reasonably, to be the cause of the patient’s symptoms.
Most procedures performed by Dr Onuma for adhesiolysis in the abdomen and pelvis are carried out through laparoscopic (key-hole) surgery. The nature of the laparoscope allows magnification of the operating site allowing a better and more close-up view than with the naked eye (as in open surgery). Sharp dissection using fine scissors placed through small ports in the abdominal wall and the use of atraumatic graspers means that tissue can be kept under tension with minimal risk of injury during dissection.
There are numerous products that have come on the market for prevention of adhesions. There is no good evidence that any of them work at all, work well or work in a reproducible manner. Sharp dissection, obtaining anatomical plains, reducing blood loss and washing out the abdomen and pelvis are simple techniques which may reduce the recurrence of adhesions.
Dense adhesions of omentum to the anterior abdominal wall. Note the blood vessels. Blunt dissection would result in these vessels being sheared resulting in much more bleeding than occurs when sharp dissection is used in association with coagulation.
Coagulation or diathermy, though very beneficial in reducing blood loss, must be used with great care because of the risk of injury to close by structures such as bowel.
Examples of adhesiolysis
Postmenopausal. Intermittent pain for 4 years. Worse in the last 2 years. No previous pelvic surgery. The patient had been consented for removal of both ovaries and fallopian tubes and this was carried out.
A complex mass reported on ultrasound in the left adnexal region: cystic left ovary, cystic fallopian tube and descending colon stuck to ovary and pelvic sidewall.
The descending colon has been freed from the left pelvic sidewall and is in the process of being released from the pole of the left ovary.
The left ovary and fallopian tube, freed from adhesions, held away from the left pelvic sidewall in preparation for removal.
Underwent hysterectomy 12 years previously. Pain and discomfort in lower abdomen/pelvis for 18 months. Gallbladder removed 5 years previously and appendicectomy as a child.
The Pouch of Douglas is obliterated by adhesions of descending colon and omentum.
Laparoscopic adhesiolysis over a period of 50 minutes has cleared the bowel and mental tissue from the Pouch of Douglas.
Further adhesiolysis is required to free the adhesions of the descending colon from the left abdomino-pelvic sidewall and adnexal structures.
During laparoscopic surgery the trocar, through which the telescope will be passed, is introduced into the abdomen just below the umbilicus. If there is bowel stuck to the abdominal wall on the underside of the umbilicus then there is a risk of bowel injury.
Benefits of adhesiolysis and scar tissue revision
Risks of adhesiolysis and scar tissue revision
- Related to surgery generally.
- Related to anaesthesia.
- Specific to laparoscopic or open surgery if adhesions are in abdomen or pelvis.
- Recurrence of adhesions or scar tisse.
- Ongoing symptoms despite adhesiolysis or scar tissue revision.
The problem of recurrence
Scar tissue shares a common problem with adhesions. The risk of recurrence of both is quite significant. With adhesions, recurrence rates can be as high as 80%. For scar tissue recurrence can be up to 50%. Up to 30% of women who have surgery for symptomatic adhesions or scar tissue have a greater than 30% risk of having further surgery for recurrence of symptoms. This means that patients intending on undergoing surgery need to be very carefully counselled and have a realistic expectation of the outcomes of surgery.