Post operative adhesions and management
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Post operative adhesions and management
- 2. ADHESIONS • Fibrous tissue bands that result from peritoneal injury • Can constrict hollow organs and are a major cause of postoperative small bowel obstruction • Most remain asymptomatic ; but can arise anytime after the 2nd postop week to years after surgery
- 6. ADHESIOLYSIS • Surgery that is performed to remove or divide adhesions so that normal anatomy and organ function can be restored and painful symptoms can be relieved.
Editor's Notes
- A bandlike adhesion ( ) between loops of small intestine is shown. Such adhesions are most likely to form after abdominal surgery. More diffuse adhesions may also form after peritonitis. Adhesions may predispose to bowel obstruction when loops of bowel become trapped in the abnormal opening created by adhesions. In populations in which prior abdominal surgery for various conditions, such as acute appendicitis, has been performed, adhesions are often the most common cause of bowel obstruction. The presence of abdominal scars on physical examination of a patient with acute abdominal pain, distention, and ileus is a clue to this diagnosis.
- Adhesions may appear as thin, avascular sheets of tissue similar to plastic wrap or as thick, vascularfibrous bands of adhesions, which are considered the more severe and more difficult to remove. In some rare cases, adhesions form without visible or known tissue trauma. While some adhesion formation is part of the normal healing process, in some cases excessive scar tissue can develop, disproportionate to the original injury. As is shown in the pictures below, adhesions can bind your organs or tissue together in a way that begins to cause pain, organ dysfunction, or other symptoms. In some rare cases, adhesions can even cause life-threatening injuries, such as bowel obstruction.
- Adhesions form when there is damage to the visceral or parietal peritoneum, and the basement membrane of the mesothelial layer is exposed to the surroundings. Causes of peritoneal injury include irritation and damage from infection, ischemia, mechanical trauma, or exposure to various chemicals. This injury induces an inflammatory reaction whereby mast cell breakdown occurs, vascular permeability increases, and a fibrinous exudate is produced. This exudate is then transformed into a fibrin matrix covered with mesenchymal cells, fibroblasts, and macrophages, and enables tissue repair to occur. Although this fibrin matrix is essential for the healing process of normal peritoneum, its dissolution is also necessary so that adhesion formation does not occur. This dissolution is mediated by the fibrinolytic pathway where plasminogen is converted to its active form, plasmin, which then degrades fibrin. Normal fibrinolytic activity usually prevents fibrinous attachments for 72 to 96 hours after surgery. Mesothelial repair occurs within 5 days of trauma and this process of peritoneal healing differs from that of skin as observed by Hertzler. When a peritoneal defect is made, repair is not initiated at the borders of the defect, but rather, the entire surface becomes epithelialized spontaneously. This phenomenon allows small defects to heal as quickly as larger ones. Figure 1. When the fibrinolytic activity of the peritoneum is suppressed, fibrinous adhesions are formed and persist, as collagen deposition and neovascularization occur.
- Surgery is currently the only treatment that can effectively remove adhesions. A problem with this treatment, however, is that surgery itself can contribute to the formation of new adhesions. For this reason it requires a high level of expertise and special techniques to surgically treat adhesions while minimizing the risk of recurrence.