Patients with adhesions inside the abdominal cavity. Adhesions can come in various sizes, length and structure. No matter what the size they can cause abdominal pain, discomfort, bloating, and difficulty with bowel movements
Adhesiolysis or Lysis of Adhesions
Adhesiolysis is the process of cutting the adhesions between two abdominal structures. Here, Dr. Miklos uses scissors to cut or release the adhesive disease between the abdominal wall and the bowels' protective fatty covering called the "great omentum."
Chronic pelvic pain is a debilitating disease that affects more than 20% of women today. Much of the pelvic pain is caused by scar tissue known as adhesions. Adhesions are bands of scar tissue that connect normally separated pelvic structures. This connection represents a common problem in gynecologic health care which causes incapacitating pelvic pain, infertility, constipation, and dyspareunia (painful intercourse). Patients are more likely to have adhesive disease after an injury. The injury can be caused by surgery, infection, radiation or trauma to the abdominal area. (See causes below.)
Causes of Pelvic Adhesions
- Previous pelvic or abdominal surgery (most common reason)
- History of infection in the abdominal cavity
- History of cancer or radiation therapy
- Previous intra-abdominal trauma or bleeding (ectopic pregnancy, motor vehicle accidents, appendicitis)
- Surgical glove powder
Adhesions are almost inevitable after a surgical procedure as indicated by the bar graph. It is up to the surgeon to minimize the potential of adhesion formation. Drs. Miklos and Moore are aware of this problem and perform specific adhesion prevention techniques to avoid the formation of new adhesions while trying to eradicate the already existing adhesive disease.
Source: Adapted from Diamond MP. Surgical aspects of infertility. Gynecology and Obstetrics, 1998
Drs. Miklos and Moore minimize adhesion formation by incorporating minimally invasive open laparoscopy (see below) and using barrier membranes and gels. The open laparoscopy technique is a safe and proven technique. Please refer to an article in Obstetrics and Gynecology describing a 29 year experience with open laparoscopy.
The belly button incision is performed with a scalpel instead of a blind stab with a Veress needle. The Veress needle and trocar insertion injuries are unique to conventional laparoscopy. By utilizing the open laparoscopy technique, we can closely monitor the entry into the abdomen to see if there are any adhesions, bowel, or blood vessels in the way. If we encounter an injury, we can recognize and repair it immediately. Because of our experience in advanced laparoscopy, we add an additional edge in the prevention of adhesions over an open laparotomy.
Adhesion Prevention Techniques
- Gentle Tissue Handling
- Use of Barrier Agents (Interceed or Intergel)
- Use of Microsurgical Instruments
- Precise Treatment of the Surgical Area
- Minimal Blood Loss
- Copious Pelvic Irrigation
- No Glove Powder Exposure
Open Laparoscopy Technique
Injecting Incision Site - incision site prior to the incision theoretically reduces the postoperative pain the patient feels
Incision – the incision is made in the inferior border of the belly button
Abdominal Fascia – the abdomen fascia is grasped with two clamps and incised. The fascia is the tissue which holds the abdominal wall together and along with the abdomen muscles gives the abdomen strength
Suture Tags of Fascia - sutures are placed on the edges of the fascia so the surgeon can better identify the fascia at the end of the case. Meticulous closure of the fascia helps to prevent hernia formation.
Hasson trocar placement – the trocar is the tube which allows the surgeon to access the inside of the abdomen. This particular tube will allow the surgeon to place the laparoscope (camera scope) into the belly thus permitting visualizaiton of the procedure and adhesions.
Adhesiolysis Surgical Technique
The goal of adhesiolysis is to eliminate pain caused by the adhesion or scar tissue. Many surgeons use laser, electroenergy or electrocoagulation to perform this procedure. Drs. Miklos and Moore perform laparoscopic adhesiolysis using scissors, just as they would do if they did the surgery through a large open incision. They utilize precise surgical technique with minimal bleeding during the adhesiolysis thus preventing further damage and potentially more adhesions. They believe that laparoscopy is only a mode of access into the abdominal cavity and should not change the way one performs the operation. To prevent future adhesions, Drs. Miklos and Moore utilize anti-adhesive barriers.
They agree with a recent study in the Journal of Laparoscopic Surgeons that advocates the combination of laparoscopy and adhesion barriers.
Drs. Miklos and Moore are also involved in ongoing multi-center research trials involving new adhesion barriers. Because of the laparoscopic approach, most patients undergoing adhesiolysis usually remain in the hospital for less than 23 hours.