Abstract
Treatment of pain caused by abdominal and pelvic adhesions is possibly one of the most controversial issues among physicians taking care of patients with pelvic pain, and science is not helpful. There are publications that show that adhesions do not cause pain and others that show they do. The same goes for usefulness of adhesiolysis to relieve that pain. This discrepancy may be due to the fact that some surgeons preform more complete adhesiolysis than others and that coexisting pain conditions may be an additional confounding factor. I believe that certain adhesions cause pain and, in many cases, adhesiolysis is helpful. Laparoscopic or robotic adhesiolysis is a preferred way because chances of recurrence of adhesions is decreased. This may be due to the fact that CO2 prevents fibroblast migration. Risks of adhesiolyis including a risk of unrecognized bowel injury have to be very clearly explained to the patient and this procedure should be performed only by a skilled surgeon.
Editor’s Introduction
Treatment of pain caused by abdominal and pelvic adhesions is possibly one of the most controversial issues among physicians taking care of patients with pelvic pain, and science is not helpful. There are publications that show that adhesions do not cause pain and others that show they do. The same goes for usefulness of adhesiolysis to relieve that pain. This discrepancy may be due to the fact that some surgeons perform more complete adhesiolysis than others and that coexisting pain conditions may be an additional confounding factor. I believe that certain adhesions cause pain and, in many cases, adhesiolysis is helpful. Laparoscopic or robotic adhesiolysis is a preferred way because chances of recurrence of adhesions is decreased. This may be due to the fact that CO2 prevents fibroblast migration. Risks of adhesiolyis including a risk of unrecognized bowel injury have to be very clearly explained to the patient and this procedure should be performed only by a skilled surgeon.
Etiology
Pelvic Adhesive Disease
Postoperative adhesion formation occurs virtually after every intraperitoneal surgery [1]. It is one of the most common findings in women with pelvic pain [2]. It is estimated to account for up to 50% of patients with pelvic pain [3]. Other causes of pelvic adhesive disease include the byproduct of infectious stimuli, for example, pelvic inflammatory disease (PID). The adhesive disease generated by PID acts in a protective manner by isolating the harmful microorganisms. Germ cell tumors, such as dermoid cysts, cause a chemical peritonitis and precipitate pelvic adhesion formation in a similar, isolating manner as seen with infectious etiologies. Other gynecological conditions, especially endometriosis, produce and enrich pelvic adhesive disease.
The formation of pelvic adhesive disease follows a cascading process; it is subject to various physiological and pathological pathways depending upon the extent of the initial injury and the subsequent response. Pelvic adhesive disease formation starts with an injury to the peritoneum, most notably as a natural response to surgery. The pathological process develops mostly as a consequence of mechanical, thermal, or devascularization trauma during a surgical procedure [4]. Disruption of the peritoneal surface produces an inflammatory response [5]. Subsequently, the activation of white blood cells, macrophages, and platelets occurs [4]. As a protective measure, fibroblast recruitment produces fibrin deposition to the denuded surfaces, and, if not degraded, will ultimately result in collagen deposition with subsequent pelvic adhesion formation [4]. As a result of this peritoneal trauma, the cascade of inflammation, mesothelial repair, and incomplete fibrinolysis contributes to the development of pelvic adhesive disease [6]. The common denominator of pelvic adhesive disease formation, regardless of the etiology, is determined by the exaggerated inflammatory response, decreased fibrinolysis, extracellular matrix deposition, and incomplete remodeling [7]. Prostaglandin formation also is involved with adhesion formation in in vitro studies [8].
Pelvic Pain
Pelvic pain arising from pelvic adhesive disease is a complex, variable, and unpredictable condition that has plagued gynecological surgeons for centuries. The consequences of pelvic adhesive disease are many, but the most distressing sequela is the development of pain, especially pelvic pain, and has the potential to traumatize patients and frustrate gynecological surgeons. The etiology of this pain is unknown, but is thought to involve the disruption of normal organ mobility [9]. This mechanical cause of pelvic pain may be the direct consequence of excessive traction of the adhesive disease against well innervated viscous organs. As a result, this traction adversely stimulates visceral and parietal peritoneum, producing the noxious response [10, 11]. Pelvic adhesive disease is a significant contributor to chronic pelvic pain syndrome [10, 12]. This cause-and-effect theory makes logical sense, but the entire process may be more complicated. Debilitating pelvic pain resulting from pelvic adhesive disease can contribute to the central sensitization of pain, thus further complicating diagnostic and therapeutic interventions [13–15]. Correlation between the location of the pain symptoms and the commensurate anatomical site, unfortunately, is not clear. The anatomical site of adhesive disease is not necessarily associated with the amount of pain [16]. But the consistency and architecture of the tissue may guide gynecological surgeons [17]. Pain localized to the abdomen is usually associated with bowel and omental attachment to the lower portion of the abdominal wall. Dyspareunia as a result of pelvic adhesive disease can be the result of adhesions to the uterus, adnexa, and cul-de-sac [17]. While the anatomical site can provide the surgeon with some guidance into the areas of therapy, it is not foolproof. The etiology of pelvic pain may not be due to its anatomical site and may be due to the presence of the adhesion itself. This confounding factor may be due to the fact that adhesive disease itself contains de novo nerve tissue and may contribute to the clinical symptoms [18–20].
Concerns
In addition to pelvic pain, pelvic adhesive disease promotes infertility, dyspareunia, bowel obstruction, and increased risk of injury with subsequent surgical intervention. Cesarean section, myomectomy, and adnexal surgery are the three highest risk gynecological procedures that promote postoperative development of pelvic adhesive disease [21, 22]. The most devastating consequence of adhesive disease is the increased risk of postoperative bowel dysfunction and obstruction [1]. This is a critical consideration when planning operative removal of adhesions, and an important part of the preoperative informed consent.
Symptoms
Pelvic pain arising from pelvic adhesive disease may not have consistent symptomatology; in addition, its presentation can be confounded by other concomitant gynecological or nongynecological conditions. When pelvic adhesive disease constrains or restricts movement of viscous organs in the abdominal cavity, movement of the underlying encased tissue generates a pain response. In the case of adhesive disease to the bowel, the pain may be precipitated with ingestion of food, bowel movements, or normal gut motility. This type of pelvic pain is usually described as a pinpoint pain response. Adhesive disease to the female pelvic organs can manifest as dyspareunia or uterine or adnexal pain. Persistent pain at cesarean section scar is another example of localized pain and may be the result of adhesive disease. Dysmenorrhea is usually separate from pelvic pain arising from adhesive disease and its presence may help with deciphering the etiology. Documentation of pelvic pain is cumbersome and prone to nebulous descriptions because there are no standardized descriptors. Research examining this issue is difficult, and most studies are fatally flawed, as gynecologists are unable to reliably reproduce the symptoms. Additionally, validated scoring systems to accurately document the extent of disease and its clinical and research implications are not available [6].
Prevention
Prevention of postoperative adhesion formation is critical for all gynecological surgeons. This includes, but is not limited to, meticulous surgical technique with prevention of excessive tissue trauma [23]. Other preventative measures include minimization of tissue ischemia and desiccation, as well as prevention of infection and foreign body retention [3]. Postoperative adhesion formation produces adhesions for up to seven days after the procedure [3]. Ideally, administration of an adhesion blocking measure would have to be available for that amount of time. For a time, there was great promise with use of adhesion preventing measures, but unfortunately, use of adhesion barriers or intraperitoneal irrigates suggests a suboptimal, if any, response to combatting pelvic adhesive disease [3]. The authors cannot recommend any of these measures. Closure of the peritoneum, a long held paradigm in gynecological surgery, is no longer recommended as a way to prevent pelvic adhesive disease [24]. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) or blood thinning medication lacks efficacy [3]. Use of laparoscopy over laparotomy appears to convey a benefit of decreasing adhesion formation [25].
Diagnosis
The preoperative workup includes a thorough history documenting symptoms and attempting to localize the pain. If the pain is isolated to a particular area, as opposed to a generalized complaint, then the surgeon may have a greater opportunity to address the issue. Generalized complaints of pain, while still important findings, may not be necessarily due to adhesive disease, and surgical exploration in these patients will yield less optimal intraoperative and postoperative results. A more structured assessment of pain via standardized pain score testing is limited, as it does not correlate well with degree of pain both preoperatively and postoperatively [26]. Standardized questionnaires, however, such as those produced from the International Pelvic Pain Society, may be useful [27]. Physical exam, especially abdominal and pelvic portions, may pinpoint the disease process. Adherent attachment of the uterus to the abdominal wall, tenderness at cesarean section site, fixed pelvis, decreased bladder capacity, and bowel complaints all may help pinpoint the affected area. Imaging modalities and laboratory assessment are not usually beneficial. Diagnosis of pelvic pain from adhesive disease is primarily made intraoperatively and remains the most accurate means of making the diagnosis [28].
Treatment
Surgical removal of adhesive disease is a major procedure in the United States, with 400,000 cases performed daily, costing in excess of $1.3 billion every year [3]. Surgical treatment options are wide, varied, and, unfortunately, weakly supported by academic studies. The only two randomized controlled trials examining the effect of adhesiolysis on pelvic pain each have serious methodological flaws [3, 29]. Despite the scarcity of convincing research, patients with pelvic pain arising from pelvic adhesive disease may benefit from adhesiolysis [17]. The authors of this publication concur. An existential question arises with patients afflicted by pelvic pain arising from adhesive disease: what can a gynecological surgeon do to help alleviate the suffering in these patients with pelvic pain? As surgeons, we must rely on sound clinical judgment when treating patients with pelvic adhesive disease, and advocate adhesiolysis as a treatment for pelvic adhesive disease in certain patients. The location and extent of adhesions must be considered when planning surgical approach. Laparoscopic adhesiolysis is preferred over an open approach because of decreased length of recovery and extent of adhesion recurrence [30]. If there is concern for adhesions at the umbilicus, initial trocar can be placed at the left upper quadrant to avoid unintended bowel injury [31]. During lysis of adhesions, it is important to maximize visualization and avoid injury to surrounding structures. Sharp dissection should be utilized when organs are nearby to avoid injury; cautery is especially useful on vascular tissue. The ultimate goal of adhesiolysis should be to resect the offending scar tissue and return structures back to their anatomical positions while minimizing the extent of dissection. Counseling and managing pain expectations preoperatively are important prior to adhesiolysis. Preoperative evaluation is also important. If patients complain of localized or pinpoint pain, suggesting adhesive disease encasing an organ, then removal of the offending tissue is warranted [17, 32]. Adhesiolysis is especially useful in patients with well vascularized adhesive disease to the bowel [29]. Direct visual inspection of tissue composition may also offer the surgeons some guidance. Thin, filmy adhesions are associated with the most pain, especially when tethered to visceral organs [33]. Removal of dense, adherent adhesive disease referred to as “abdominal cocoon” will less likely provide relief [1]. Adhesiolysis for generalized pelvic pain may be less successful, but may be an important adjunct of their diagnosis and therapeutic care. Even with detailed preoperative screening and meticulous intraoperative technique, the most devastating, and, at times, unpredictable postoperative consequence is the return of symptomatic pelvic adhesive disease [10, 25, 33]. Benefits of adhesiolysis are still murky, and until definitive studies come forth, adhesiolysis for pelvic pain secondary to pelvic adhesive disease can be used judiciously [20]. Noninvasive strategies such as humidified CO2, human amniotic membrane, or pharmaceuticals to prevent adhesion formation generally deliver suboptimal results [7]. Additionally, adhesion barriers for pelvic pain secondary to pelvic adhesive disease are limited and are based on insufficient outcome analysis [34].
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