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The peritoneum is a membrane that protects the abdominal organs from rubbing and injuring each other. It is so delicate itself that a slight trauma is enough for it to form a union. Sometimes gentle, sometimes life-threatening.
It is the largest membrane in the human body. It is thin, smooth, lines the inside of the abdominal cavity and the pelvis, and covers all or part of its organs. The peritoneum plays a similar role to the pleura that surrounds the lungs and the pericardium that covers the heart. All three are composed of cells that produce serous fluid, the task of which is to reduce friction and allow the “protected” organ to move freely and safely in relation to other tissues and organs. The peritoneal membrane is an extremely delicate “guardian”. A slight irritation is enough for the injury to form a fusion – an abnormal inter-tissue connection. These anomalies can be congenital, but over 90% of them are acquired. Abnormalities arise mainly as a result of inflammation or irritation or mechanical damage to the peritoneal epithelium during surgery and are the most common complication in abdominal and small pelvic surgery. They can be caused by, for example, touching and pulling the viscera, or drying or rinsing the peritoneum during surgery. The size of the membrane damage is also influenced by its ischemia during the procedure, the chemicals used during the procedure, as well as the presence of foreign bodies in the peritoneal cavity, e.g. surgical threads, which the body cannot absorb, and talcum particles from damaged gloves. Post-operative adhesions can form between tissues and organs throughout the body (e.g. after thyroid or joint surgery). Wherever the tissues are cut, all or part of an organ is removed or the serosa is irritated.
The scars are menacing but invisible
Postoperative adhesions in the peritoneal cavity may form after each – even small – opening, e.g. during removal of an inguinal hernia. Registrations of clinical cases show, however, that they most often arise after three types of procedures: resections of the large intestines, gynecological surgeries on the ovaries and fallopian tubes, and appendectomy. Adhesions take the form of bands and membranes of various structures – from thin and almost transparent to solid, thick and dense. The process of the formation of a union (adhesion) begins immediately after damage to the peritoneal membrane. The “wounded” epithelium wants to be regenerated quickly. A clot develops from the edges of the defect towards its center, closing the blood vessels, and then the inter-tissue connections are rebuilt. A thick layer of fibrin accumulates in the damaged area, which undergoes the so-called fibrinolysis, or dissolution. If the process of epithelial reconstruction proceeds smoothly, as a result of fibrinolysis, the fibrin deposits disappear almost completely and the scars in their place are small. However, with more extensive damage or, for example, longer exposure to the harmful factor, the “regeneration” of the epithelium is much slower. Then the fibrin begins to cover or stick (with each other or with the peritoneal membrane) of the organs in the abdominal cavity. The question of whether or not the fusion will occur, and if so, where, what type and how extensive it will be, is decided already within 3-5 days of the operation. This is how long it takes for the peritoneal membrane to heal properly.
Inhibited fertilization
Adhesions can be deceptive. On the one hand, they can remain “dormant” for many years without disturbing the functioning of individual organs and without causing any ailments. But they can also cause chronic or recurring pain at various intervals, most often located in the lower abdomen. This pain, when combined with other symptoms, can be a sign of various types of gastrointestinal dysfunction as a result of adhesions induced in the intestines. In women who have undergone more or less open and complex minor pelvic surgery, pain may be a signal that adhesions have disrupted the natural function of this area. This has both anatomical and functional consequences. It turns out that postoperative adhesions are the main cause of the so-called female acquired infertility. There is no ovulation in the ovaries covered with adhesions. And if adhesions have formed in the fallopian tubes, the movement of the eggs or the developing embryo is difficult or even impossible. As a last resort – postoperative adhesions in the genital tract also cause miscarriages (often multiple). On the other hand, in women diagnosed with endometriosis, adhesions may form both as a result of the disease itself (endometriosis causes local inflammation, which determines the formation of adhesions) and after its surgical treatment. In extreme cases, the adhesions formed in this way can grow so large that they immobilize the uterus.
Intestinal obstruction
The most common and serious consequence of postoperative adhesions, however, is intestinal obstruction, i.e. the stoppage of the process of the passage of food through it. Mechanical obstruction may result from either obstruction of the intestine (e.g. cancerous tumor, polyp, foreign body, gallstones) or the so-called stiff intestine caused by e.g. twisting the intestine around its axis (most often at the end of the large intestine, i.e. the sigmoid colon) or compression of the intestine by postoperative adhesions. Normal intestinal peristalsis is also inhibited after each opening of the abdominal cavity. This type of obstruction, the so-called paralytic, it usually lasts a few days, and then the intestines begin to work in their own rhythm. With mechanical obstruction, shortly after being clogged or strangulated, the intestines begin to move faster, trying to remove the barrier with these faster movements. If they fail to do so, more and more food and gas build up just in front of the dam, causing pressure to build up and the intestine to become distended. The walls of the intestine become thinner and thinner and its movement stops. This is really dangerous. The digestive juices begin to accumulate in the intestine (the daily dose is approx. 8–9 liters), because their absorption is blocked. The most dangerous changes – ischemia and hence necrosis – take place in the loop of a cramped intestine. In addition, this is where microorganisms multiply, which easily penetrate the thin wall of the intestine, causing peritonitis or septic conditions. In addition, holes are formed in the dead intestine through which intestinal contents escape into the abdominal cavity. If the obstruction is located in the small intestine (or – rarely – in the stomach or duodenum), then the obstruction is called high, and if in the large intestine – low. Specialists also mention acute obstruction, when symptoms appear suddenly and proceed rapidly, and chronic – the so-called permeable. In the latter case, the signs of obstruction occur periodically, which means that e.g. the fusion did not completely close the intestine, but only narrowed it. Intestinal obstruction is a disruption of a complicated but basic process for us, which is digestion and assimilation of life-giving ingredients. Symptoms of obstruction vary depending on its cause. The most characteristic and requiring immediate surgical intervention are – severe abdominal cramps, recurring and resolving after a sudden solstice every few minutes, the sound of “overflow” of intestinal contents, vomiting, bloating, gas and stool retention, as well as a drop in blood pressure, increased heart rate. If the obstruction is in an advanced stage, there is fever, electrolyte disturbance, dehydration and cachexia, as well as disturbed consciousness. In the absence of prompt diagnosis and initiation of treatment, intestinal obstruction leads to death in up to 10% of cases.
Profilaktyka i pharmakologia
In order to completely eliminate the risk of the formation of adhesions, one would simply have to abandon the surgery. However, many dysfunctions in the functioning of internal organs cannot be treated pharmacologically. So far, no other methods of reaching the abdominal cavity organs have been invented, other than its full opening (laparotomy – cutting the skin, muscles and peritoneum) and “repairing” external organs or “inserting” surgical instruments into it through small openings in the abdominal wall (laparoscopic technique ). The latter, being less invasive, is becoming more and more popular among surgeons. In the case of postoperative adhesions, laparoscopy is used to determine the place of their formation, type, extent, and to release them – the so-called surgical adhesiolysis. It is usually discontinued in patients who have already had two or more laparotomies. Of course, a solution would be to inform the patient before the operation about the possible risk of adhesions. Unfortunately, this is not a binding procedure in Poland. It cannot be denied that both methods of adhesions release involve successive interference with the structure of the peritoneum and other organs, and therefore may lead to their re-formation. This is why surgeons pay great attention to anti-growth prophylaxis. It includes several elements. The first is the use of appropriate surgical techniques – e.g. gentle handling of tissues, moisturizing the peritoneal membrane, leaving the smallest possible ischemic areas in the surgical field, observing the rules of microsurgery (especially in laparoscopy), rinsing the gloves before surgery and using appropriate tools (laser, harmonic knives) ) and absorbable sutures. The second element is pharmacological treatment with anti-inflammatory and antihistamines, and the third is the use of modern physical barriers (special membranes that are not absorbable, so another treatment is needed to remove them, and soluble liquid and gel substances, such as Hyalobarrier Gel). Such barriers are designed to separate the damaged surfaces of the peritoneal membrane and organs, and thus allow them to heal properly.
High-risk treatments
Postoperative adhesions are most often formed after the following procedures: • on the large intestine – especially after resection; • on the reproductive organs – eg after removal of ovarian cysts, endometriosis, ectopic pregnancy, adnexal adhesions, uterine fibroids (especially on the posterior wall), after various types of hysterectomies (removal of the uterus), after sterilization of the fallopian tubes and cesarean section; • appendectomy.
Research to help identify and cause intestinal obstruction
• Blood analysis – with longer-lasting obstruction, for example, water and electrolyte disturbances (sodium, potassium and chlorine levels decrease), and the blood pH becomes more alkaline. • Urine analysis – eg with severe obstruction, its specific gravity increases. • X-ray image – one of the oldest and most effective examinations of the gastrointestinal tract. They are performed in a standing position. If there is no suspicion of complete intestinal obstruction or perforation, the so-called contrasts. Single-contrast method – the patient is given a water-insoluble, but strongly absorbing X-ray rays, the so-called positive contrast in the form of liquid or slurry (e.g. barium), to be drunk or via a gastric tube. The area filled with contrast, along with all distortions of the digestive system, is visible on the monitor of the X-ray film club. Two-contrast method – in addition to positive contrast, the patient also receives negative contrast, air or other gas (introduced through a probe or in the form of a gas-releasing powder) that fills the intestines and gives them shape. In X-ray of the large intestine, both contrasts are administered through a tube inserted into the rectum. • Computed tomography and magnetic resonance imaging – imaging tests that help identify the cause and location of the obstruction in the digestive tract.
See if you can have adhesions
Answer the following questions and mark the correct answer: Have you ever had a gynecological operation (ovaries, fallopian tubes, uterus, fibroids removal)? If so, was it a laparotomy (classic abdominal opening)? Have you had a curettage of the cervical canal and uterine cavity walls (e.g. after childbirth, after a miscarriage)? Have you ever had abdominal surgery (e.g. gallbladder, colon, appendix)? If so, was it a laparotomy? Have you ever had a diagnostic laparoscopy? Are you currently receiving treatment for endometriosis? Have you ever had ovarian inflammation? Have you given birth by caesarean section? Do you experience chronic pain in the abdominal area? Do you have difficulty getting pregnant? Do you experience pain during sexual intercourse? Do you have painful periods? Do you suffer from constipation and gas (after colonoscopy has been excluded)? Have you had surgery to release adhesions in your pelvis? If the answers to “YES” are predominant, you may be dealing with a compound disease. Therefore, it is best to ask for a consultation with a gynecologist.
Text: Magdalena Gajda
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