This document discusses pelvic adhesions, which are scar tissues that form after abdominal surgery, infections, or endometriosis. It covers the epidemiology, pathophysiology, risk factors, diagnosis, classification, causes of infertility, prevention, and treatment of pelvic adhesions. Adhesions are commonly treated through laparoscopic or microsurgical adhesiolysis to relieve pain and improve fertility outcomes.

1. PELVIC ADHESIONS
AND
ADHESIOLYSIS
Osama M Warda MD
Professor of Obstetrics & Gynecology
-Mansoura University-EGYPT

2. BACKGROUND
Ò Pelvic adhesions are considered to be post-
inflammatory scar tissues that are formed after
abdominal surgery, endometriosis and intra-
abdominal infections.
Ò Adhesions may also be a severe and sometimes
life-threatening complication.
Ò Although no universal nomenclature exists, they
can be described as dense or flimsy, thick or thin,
opaque or trasluscent and vascular or avascular.

3. EPIDEMIOLOGY
Ò 3.5% of laparotomies is for adhesive intestinal
obstruction.
Ò 0.9% of all admissions.
Ò SCAR group - 1 in 3 post laparotomy pts. are
readmitted over 10 yrs.
Ò Mostly due to surgeries on ovaries and
fallopian tubes in gynae. and colon & rectum in
general surgery.

4. PATHOPHYSIOLOGY.
- Abnormal connective tissue attachments
between tissues and organs( Internal scars).
- Congenital or Acquired.
- Trauma to the peritoneum:
* Surgical or inflammatory.
* Ischaemia.
*Dessication or overheating.
*Irritation from foreign materials.
*Wound healing.

5. RISK FACTORS
1- Intrabdominal Infections: (Pelviperitonitis).
- Inflammatory pelvic disease.
- Acute appendicitis.
- Perihepatitis.
- Others.
2-Abdominal Surgery.
3- Peritoneal Endometriosis.
4-Intraperitoneal tissue ischemia:
5- Cauterization, Ligatures.
6- Devascularization.
7- Dryness of the serosa.

6. DIAGNOSIS
a) Anticepation (risk factors).
b) Clinical manifestations ( infertility, p pain, fixed ut)
c) Lab tests ( inflam. , HSG)
d) Magnetic Resonance Imaging (MRI).
e) Laparoscopic diagnosis (FINAL)

7. DIAGNOSTIC CONSIDERATIONS
Ø Only a small percentage of patients with chronic
pelvic pain have laparoscopically documented
adhesions.
Ø 27% of patients without any remarkable history of
adhesions present on laparoscopy.
Ø Aproximately 50% of patients with 2 or more
factors in their history really have adhesions.
Ø An abnormal pelvic examination is useful in
predicting the presence of adhesions in 74% of the
cases.

8. LAPAROSCOPIC CLASSIFICATION OF PELVIC
ADHESIONS
Stage I: Present around the fallopian tube, ovary
or other area, but without impeding ovum
capture.
Stage II: Present between the fallopian tube and
the ovary or between these structures and other
areas and may impede ovum capture.
Stage III: Torsion or occlusion of the fallopian
tube or complete blockage of ovum capture

9. PELVIC ADHESIONS CAUSE INFERTILITY IN
WOMEN THROUGH VARIOUS MECHANISMS:
1- Mechanical action: interfering with the motility,
ovular capture and transportation by the fallopian
tubes.
2- Immunologic action on the ovum: by the
immunologic mechanisms mediated by lymphocytes,
HLA, HAY etc.
3-Interference with the ovarian cyclic function: when
the ovary is covered by adhesions.

10. PROPHYLAXIS OF ADHESIONS: STEPS
1. Reduce tissue trauma: decrease inflamatory reaction,
and liberation of exudates.
2. Inhibition of coagulation in the exudate that’s formed.
3. Elimination of the fibrin deposits (fibriolytics).
4. Aviodance of the union of bare surfaces covered with
fibrin.
5. Stop the scarring process, especially the proliferation of
fibro/plastic tissue.
6. Achieve perfect hemostasis and avoid the formation of
blood clots.

11. Adjuvant agents for adhesion reduction.
Fibrinolisin.
Streptokinase.
Urokinase.
Hyaluronidase.
Chemotrypsin.
Trypsin.
Tissue activators of
plasminogen.
Low molecular weight Heparin.
Oxalates.
Citrates.
1- Fibrinolytic Agents:
2- Anticoagulants:
Diamond MP, DeCherney AH: Pathogenesis of adhesion formation/reformation: application to
reproductive pelvic surgery. Microsurgery 8:103, 1987.

12. Tetracyclines.
Cephalosporins.
Corticosteroids.
Antihistamines.
Progesterone.
Calcium channel-blocking
agents.
Nonsteroidal anti-
inflammtory drugs.
Ketorolac
tromethamine.
Phenylbutazone.
Ibuprofen.
Indomethacin.
3-Antibiotics:
4- Anti-
inflammatory
drugs:
Diamond MP, DeCherney AH: Pathogenesis of adhesion formation/reformation: application to
reproductive pelvic surgery. Microsurgery 8:103, 1987.

13. Dextran
Silicone.
Povidine.
Mineral oil.
Petrolleum Jelly.
Crystalloid solutions (Ringer lactate)
Sodium carboximethylcellulose.
Oxidized cellulose.
Regenerated oxidized cellulose.
Gelatin.
Polytetrafluoroethylene
Bioabsorbable hydrogel barrier.
Rubber sheets.
Polaxamer 407.
Metal foils.
Plastic hoods.
5- Mechanical
separation:
6-Exogenous
barriers:
Diamond MP, DeCherney AH: Pathogenesis of adhesion formation/reformation: application to
reproductive pelvic surgery. Microsurgery 8:103, 1987.

14. Omental grafts.
Peritoneal grafts.
Bladder flaps.
Fetal membranes.
Vitamin E.
Sodium
Tolmetin.
Phospholipids:
7- Endogenous
barriers:
8-Othors:
L-phosphatidylcholine.
DLa- phosphatidylcholine.
Mastocyte
stabilizers:
Diamond MP, DeCherney AH: Pathogenesis of adhesion formation/reformation: application to
reproductive pelvic surgery. Microsurgery 1987; 8:103.
Ellis H: The cause and prevention of postoperative adhesions. Surg Gynecol Obstet 1961; 113:
547

15. Adhesion reducing procedures
1- Microsurgery:
2-Laparoscopic
surgery:
3-Evaluative laparoscopy (Second-
look laparoscopy)
Laser CO2
Electrosurgery.
Laser.
Aquadissection.
Electrosurgery.
Raj SG, Hulka JF: Second-look laparoscopy in infertility surgery: therapeutic and prognostic value. Fertil Steril
1982; 38: 325.
Rodríguez Hidálgo N: Laparoscopía Ginecológica. Presencia Latinoamericano, Mexico. 1987.

16. Results of adhesiolysis using microsurgical techniques
Author Year Number of patients Viable gestations
(%)
Betz. 1980 29 69
Patton. 1982 35 63
Frantzen
Schlösser 1982 49 41
Donnez-
Casanas - Roux. 1986 42 64
Tulandi. 1986 33 52
In terms of pain relief, adhesiolysis produced:
Total or partial relief: 65% of the pacientes
No change: 25% of the pacientes.
Worsening of pain: 12 % of the pacientes.
Rodríguez Hidálgo N: Laparoscopía Ginecológica. Presencia Latinoamericano, Mexico. 1987.

18. Thank you