Pelvic adhesions

The endometrium is the tissue that lines the inside of the uterus. Endometriosis is a condition where endometrial tissue is found outside the uterus. It is trapped in the pelvic area and lower abdomen. The exact cause is unknown. A reflux of menstruation occurs in many women but in endometriosis refluxed cells implant in the pelvis, bleed in response to cyclic hormone stimulation and increase in size. Patches of endometriosis can cause adhesions and form into cysts which can fill with thick fluid and are known as chocolate cysts. 

Because medical conditions, emotional/behavioral symptoms, and physiologic indices change during the premenstrual and per-imenopause phases, it is important to rule out other disorders that may contribute to mood fluctuations or pain syndromes (Table 78-2). For example, dysmenorrhea may be primary, which occurs during ovulatory cycles, or secondary, which relates to pelvic pathology (e.g., infection caused by the placement of intrauterine devices, endometriosis, pelvic inflammatory disease, ovarian cyst, endometrial cancer, adhesions, and benign uterine tumors). 

In severe endometriosis, infertility likely results from distortion of the pelvic structure secondary to endometrial lesions, inflammation, and adhesions. In milder disease, the cause-effect relationship is more controversial. Decreased oocyte viability and/or production resulting from the altered uterine environment may be a contributing factor. ... 

Snrgical therapy is not withont risk. Potential complications in-clnde nterine prolapse, adhesion development with snhseqnent re-dnced fertility, and damage to or denervation of the pelvic stmcture. Risks and benefits of snrgery therefore shonld he discnssed on an in-dividnal patient basis. 

Diamond. M., Daniell, J., Martin, D., Feste, J., Vaughn, W. K. and McLaughlin, D. S., Tubal patency and pelvic adhesions at early second-look laparoscopy following intraabdominal use of the carbon dioxide laser initial report of the intraabdominal laser study group, Fert. Steril., 42, 717,1984. 

Posterior tumor growth leads to infiltration of the presacral space and sacral bone or of the perirectal space and rectum. Recurrent cervical cancer is associated with rectal infiltration in about 17% of cases. The most common site is the rectosigmoid junction. Laterally, recurrent tumor may extend to the pelvic sidewall. If the recurrent local tumor grows anteriorly along the peritoneal fold, there will be infiltration of the urinary bladder. Advanced recurrent cervical cancer may involve the remaining colon or the small intestine and is typically associated with adhesion of bowel loops and may cause intestinal obstruction. 

Fig. 7.5 la,b. Recurrent tumor of the pelvic sidewall after hysterectomy. A T2w TSE image in transverse orientation. At the right pelvic sidewall, a solid, heterogeneous mass (arrows) is depicted that infiltrates the pelvic wall and extends to the iliac bone. TUmor adhesion to the sigmoid colon, b Tlw TSE image with FS transverse orientation 1 min after administration of Gd-DTPA. MRl depicts an enhancement on the postcontrast image and central necrosis... 

Fig. 8.14. Atypical anterior location of the left ovary. CT shows atypical anterior position of the left ovary (arrow) in a patient who had undergone a series of previous surgeries and suffered from chronic pelvic pain. The ovary can be identified due to the follicles which changed in size during follow-up. At surgery extensive adhesions of the ovary and anterior abdominal wall and pelvic side wall were found...

The paracolic gutters present a common location of ovarian maldescent above the pelvic hrim. After pregnancy the ovaries may he hindered from returning to their original position due to adhesions. Furthermore, an ectopic ovarian position may he associated with adhesions, inflammation, and surgery, or result from abnormal ovarian mobility due to elongation of the broad ligaments [4] (Fig. 8.14). 

Peritoneal inclusion cysts (pseudocysts) are acciunu-lations of fluid produced by the ovaries that become entrapped by peritoneal adhesions. These lesions are typically encountered in patients with previous surgery, endometriosis, or pelvic inflammatory disease (PID). They are of variable size and tend to adhere to adjacent structures. Pseudocysts have an irregular shape because the outer surface is not a true wall but... 

CTC in symptomatic patients is to be considered when colonoscopy can not be completed or carried out this may occur due to mechanical hindrance such as pelvic adhesions, in cases of high risk of perforation as in complicated diverticular disease, when there is an obstruction due to cancer or extracolonic diseases, when the cecum cannot be reached in extreme dolicocolon conditions, or in patients with poor tolerance to colonoscopy in whom heavy sedation may be dangerous (elderly patients or patients with severe co-morbidity). Such indications are similar to those of double contrast barium enema (DCBE) however, CTC has been shown to be both more accurate and better tolerated than DCBE, and should be used preferentially whenever available (Rocket et al. 2005 Taylor et al. 2005 Taylor et al. 2006). Furthermore, in cases of obstructing colonic cancer, CTC is a valuable tool, as it can be conveniently performed at the time of a contrast-enhanced abdominal CT scan for staging purposes to detect synchronous colorectal carcinomas, metas-... 

In a porcine model for pelvic and para-aortic lymphadenectomy, the Iv mph nodes were removed from four anatomically defined locations on each side of the animal (Deprest, 1995). Solutions of 28% poloxamer 407 were applied to the four sites on either the left or the right side of the animal, and all sites on the opposite side were left untreated. After healing had taken place, adhesion formation at all surgical sites was evaluated, and each treated site was compared to the contralateral, untreated site. Adhesion formation was reduced at the sites treated with poloxamer 407 by approximately 40%. In a subsequent experiment, the temperature of the poloxamer 407 solution was maintained at O C during application to the injured area. Adhesion reduction improved to about 55% (Deprest, unpublished). 

Deprest, J.,Vergotc, 1., Evrard, V. and Broscns, I. (1995) Prevention of adhesions with the use of flogel after endoscopic pelvic and para-aoi tic lymphadenectomy in the porcine model. American Society for Reproductive Medicine, Program Supplement, S4. 

Oxidized regenerated cellulose has been used clinically as an absorbable adhesion barrier since 1989. Available as a knitted fabric (INTERCEED Absorbable Adhesion Barrier), it is the first material in the United States indicated for the prevention of post-operative pelvic adhesions. Since its introduction, additional clinical studies have been completed (Azziz et al, 1993 Sekiba et al, 1992 Franklin et al, 1995 Li Cooke 1994 Nordic Study Group, 1995) that confirm the efficacy of oxidized regenerated cellulose as an adhesion barrier. 

Azziz, R., and the INTERCEED(TC7) Adhesion Barrier Study Group II (1993) Microsurgery alone oririth Interceed absorbable adhesion barrier for pelvic sidewall adhesion re-formation, Surg Gynexol Obslet, 177, 135-9. 

Reid, R.L., Lie, K, Spence, J.E., Tulandi, T. and Yiizpe, A. (1993) Clinical evaluation of the efficacy of heparin-saturated Interceed for prevention of adhesion reformation in the pelvic sidewall of the human. In Gynecologic Surgeij and Adhesion P eventim, M.P. Diamond, G.S. diZerega, C.B. Linsky, R.L. Reid (Eds.) Prog. Clin. Biol. Res., 361, 261-64, New York Wiley-Liss. 

Keller FS, Rosch J, Bird CB (1983) Percutaneous emholiza-tion of hony pelvic neoplasms with tissue adhesive. Radiology 147 21-27... 

Another commonly-used bioabsorbable sheet is Interceed for applications in gynecologic pelvic surgery. It is a knitted fabric of oxidized regenerated cellulose which slowly turns into a gel when placed on tissues. Unlike Seprafilm , Interceed is easy to handle and can be placed via laparoscopy. It has been reported that Interceed prevents tissue adhesion effectively when blood contamination is avoided during application of it [135]. However, as complete blood evacuation is not always possible in chnical situations, surgeons are not keen to use this product. Moreover, increased adhesion formation has been observed when Interceed is applied to areas where blood accumulation cannot be prevented [136]. 

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