Pelvic Adhesions

by Nick Kongoasa MD 

I am often asked about adhesions and thought it might be helpful to explain my approach to them. 

Adhesions are formed as a protection your body provides. When you fall and skin your knee, a scab forms to protect the raw area until the skin heals. Internally, adhesions perform much the same way. They are created in response to a raw area (that can be caused by endo, or surgery, or infection or trauma. You can’t look at an adhesion and know what caused it). 

If the adhesion just covered the raw area until it healed, all would be well. However, it doesn’t work that way because all the organs in the pelvis are right next to one another. This causes the tendency for things to get adhered to or ‘’stuck’’ to the raw area. When they first form, it’s not a problem, because they are flimsy like wet tissue paper, and they are flexible. You’d not even be aware they are there. 

But over time, the adhesions can become shorter, and tighter, and harder. The flexibility disappears and they can become like concrete. Worse still, they can trap organs that should be movable and make them yank and pull. And then pain can increase, and may become constant, as organs that should be able to move freely (like an ovary or the bowel) are stuck and can’t. What to do? 

Although medical science hasn’t discovered the magic fix for adhesions, we have learned many techniques to lessen the chances that they will form. Here are the steps I take: 

1. Patient health is important both before and after surgery. You’re having surgery because of endo, but you can take measures to help your recovery. Take recommended vitamins (especially vitamin C) and probiotics. Get adequate and restful sleep. Exercise if you can. Try to reduce stress. Eat well. Don’t smoke. You want to prepare your body as best you can to face the challenges of surgical excision and recovery. After your surgery, focus on healing while increasing your activity a little each day. Start taking your vitamins, supplements and probiotics as soon as possible. Drink plenty and rest plenty. This part of the procedure is in your own hands, so take full advantage of what you can do to help yourself. 
2. We know that bleeding in the pelvis encourages adhesion formation (your body trying to help you, right?), so I take great pains to stop every bit of bleeding during surgery. This can slow the procedure, but the time spent to seal tiny bleeders is well worth it, in my opinion, if it reduces the chances of adhesion formation. I use a small instrument that looks a little bit like a staple remover (only smaller) to grasp the bleeding vessel, and then use a pulse of energy to seal it and stop the bleeding or oozing. Copious irrigation clears the field and lets me double check that all bleeding has stopped. Only then do we continue the procedure. 
3. Adhesions like to form where the tissue has become dried, so we use warmed carbon dioxide gas during the surgery, to keep the tissues moist. We also constantly use Lactated Ringers (LR) irrigation to keep the area moist. This, combined with controlling bleeding with high precision will reduce devitalized (dead) tissue and further reduce adhesions. 
4. Complete excision is paramount. We need to remove every bit of endometriosis. Even a little bit left behind can continue to cause inflammation and irritate the tissue it’s on and cause adhesions to form. All endo must be completely removed. 
5. I use PRP in surgery. PRP stands for Platelet Rich Plasma, and it is effective in helping prevent adhesion formation. Before surgery we do a blood draw from you, and spin down the blood to separate the plasma. This is then used to promote healing. It’s your own blood product, so there is no chance of rejection as we are not introducing a foreign substance. This process has been used widely in joint procedures by orthopedic surgeons. The joint is the last place where you want adhesions to form. It seemed a logical step to use it to prevent pelvic adhesions, too. 
6. I use a reconstituted amniotic membrane product in select patients. The reasoning is this. As a baby develops in the womb, she/he is a completely distinct individual from the mother. And yet, we don’t see adhesions form within the uterus after pregnancy. Reconstituted amniotic membranes also have other healing and anti-inflammatory properties. Many surgeons adapted this concept and use it to help prevent adhesions in surgical patients. 

Although there is currently no way to guarantee that no adhesions will form postop, I do feel we have a number of techniques to minimize the chances of adhesion formation. The ultimate goal is to remove all the endo and restore functionality to the pelvic organs. In my opinion, it is always worthwhile to excise all endo while taking all appropriate steps to reduce or eliminate adhesion formation.