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Adhesion & scar tissue surgery

The Australian Centre for Female Pelvic and Vaginal Rejuvenation
The Australian Centre for Female Pelvic and Vaginal Rejuvenation

What are adhesions & scar tissue?

Adhesions
Adhesions are a form of scar tissue that abnormally bind 2 or more different tissues or organs together
Scar tissue
Scar tissue forms as part of the bodies normal healing process in response to inflammation or injury. The tissue that forms tends to be more fibrous than normal tissue.

Types of scar tissue

There are five main types of scar tissue:

Atrophic
These scars are sunken down into the skin. This type of scarring is often seen with acne scars or with wounds where skin or muscle is removed by an injury. This type of scarring can also happen when the body produces so much scar tissue in one area that it prevents new cells from growing where the wound took place.
Hypertrophic
These are usually red or purple and are slightly raised above the skin. They tend to fade and get flat over time.
Contracture
These types of scars often happen with burns, and end up pulling the skin in towards the site of the injury. This can make the skin look puckered around the wound.
Keloid
These are very elevated, red or dark scars that form when the body produces a lot of extra collagen in a scar. Keloid scars are actually a benign type of tumor, and often grow bigger than the area of the original injury. Those with darker pigmented skin are thought to be more prone to keloid scarring, but it's not clear why.
Stretch
Also called striae, these are considered a unique type of scar since they don't happen in response to an injury, but because of the skin being stretched rapidly, often during pregnancy or adolescence. The tissue here is often sunken a little into the skin, and tends to fade with time.

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.

Bringing the laparoscope closer to the operating field increases magnification

Examples of adhesiolysis

Patient complaint: Sharp, stabbing left iliac fossa pain

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.

Patient complaint: Lower abdomino-pelvic discomfort and pain

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

When adhesiolysis or scar tissue revision results in complete resolution of pain, discomfort or dysfunction, the patient benefits from improved quality of life.
Benefits should always be weighed against risks

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.

Laser Vaginal Rejuvenation Institute of Adelaide
Laser Vaginal Rejuvenation Institute of Adelaide