Adhesions & scar tissue
What are adhesions?
Adhesions are fibrous bands of (scar) tissue that form between internal organs and tissues that are normally separate anatomical structures, joining them together abnormally.
Adhesions develop as the body attempts to repair itself. This normal response can occur after surgery, infection, injury (trauma) or radiation. Adhesions may appear as thin sheets of tissue (similar to plastic wrap), or as thick fibrous bands.
What is scar tissue?
Scar tissue is connective tissue that has contracted and become dense and fibrous. The connective tissue that forms a scar consists of fibroblasts in new scars and collagen fibres in old scars. Many of the factors that affect a scar are not yet completely understood.
When an opening is made through the skin, whether deliberately or by accident through some trauma, a scar results. Scar tissue can occur on the surface of the body but also occurs inside the body.
Causes of adhesions
Adhesions may be caused by:
- Injury (trauma)
- develop after any kind of pelvic or abdominal surgery – people who have major or multiple procedures are even more at risk
- cause significantly higher post-operative complications (leaks, wound infections, haemorrhages) in people with adhesion-related perforations. This may also lead to a longer stay in hospital
- lead to other risks and complications, including small bowel obstructions, infertility and chronic pelvic pain
- cause increased risk, complexity and complications during subsequent surgery.
Where do adhesions occur?
Adhesions can affect every part of the female reproductive organs and tract (vagina, uterus, ovaries and fallopian tubes) as well as all of the intra-abdominal contents.
Specific types of adhesions
The omentum is fatty tissue that covers and supports the intestines and organs in the abdomen. It functions as the abdominal ‘policeman,’ and moves towards areas affected by infection or inflammation. It adheres (sticks to) these areas in an effort to seal them off from the rest of the abdomen or pelvis, hence reducing the spread of infection or inflammation.
Chlamydia trachomatis and gonorrhoea are the two main sexually transmitted organisms associated with pelvic inflammatory disease (PID). The pelvic infection moves up to involve the upper abdomen and when liver encapsulation occurs, perihepatic adhesions result. These perihepatic adhesions are also know as Fitz-Hugh-Curtis syndrome after the two physicians who described it.
Adhesiolysis (division of adhesions)
The principle of adhesiolysis is restoration of anatomy by removing the abnormal adhesions between different organs and tissues. This is performed with the hope that restoration of anatomy is followed by restoration of normal function. This outcome cannot be guaranteed.
Adhesions recurrence is common, occurring in up to 80% of cases following surgery. The symptom response to recurrence can be quite variable.
Specific types of scar tissue
How do scars and adhesions respond to treatment?
Surgical techniques such as laparoscopic surgery and microsurgery reduce the risk of adhesion formation, but do not eliminate it entirely. Once adhesions are surgically removed, they often reform.
It is important for both doctors and patients to recognise that scars cannot be removed completely.
A variety of factors influence how a scar responds to treatment:
- Direction of the scar.
- Size of the scar
- The person’s age
- Skin type and colour
- Hereditary factors
A question of outcome
The Pouch of Douglas obliterated with adhesions. The patient has complained of lower abdominal pain and discomfort.
Adhesiolysis results in clearance of the Pouch of Douglas and restoration of normal anatomy.
Adhesion-related disorder (ARD)
Adhesion-related disorder (ARD) is a group of symptoms that may occur as a result of adhesions. A person with ARD will usually experience chronic abdominal pain.
Symptoms of ARD may include:
- chronic pain
- bowel obstruction and an inability to pass gas
- urinary bladder dysfunction
- pain and difficulty having a bowel movement
- pain on movement such as walking, sitting or lying in certain positions
- emotional disorders such as depression, thoughts of suicide or hopelessness.