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Postoperative adhesions threaten anyone who has undergone surgery. And although they cannot be seen with the naked eye, they can be a source of persistent pain and even carry a life-threatening risk.
Monika almost never hurt. Sometimes just the head and muscles, especially when she’s been working too much. Besides, she was as healthy as a fish. Strong, athletic, professionally active, she led a single life until her 35th birthday. She didn’t think about the passage of time. She had many friends and a lot of non-professional passions. She rode horses, worked as a volunteer in the zoo, danced the tango.
When she met Olaf, she fell head over heels in love. A few months later they were already living together, and Monika was wearing an engagement ring on her finger. Her closest friend was planning a bachelorette party, her mother was ordering tablecloths for wedding tables, and she quit her job to try on more wedding dresses.
– Everything happened very quickly. We got carried away, instead of getting to know each other well – says Monika.
One evening, quite suddenly, she ended up in the ER in the hospital. – My entire lower stomach ached. I was walking around the house doubled over because I couldn’t straighten up. When Olaf came home from work, I was lying on the sofa in a fetal position, completely weak and with a fever. I think it’s good that we went to the hospital quickly – recalls Monika.
Doctors suspected appendicitis, and blood tests confirmed inflammation.
– During the night I started vomiting, in the morning I was already after surgery. When I woke up, Olaf was sitting by my bed strangely excited. “After you, they operated on a girl who had adhesions after a caesarean section. I didn’t even know that something like this existed, but her husband told me everything, “he explained, and a red light flashed in my head,” Monika says bitterly.
It was then that she realized for the first time that maybe Olaf wasn’t the ideal she thought he was. He didn’t seem worried about my health, but rather fascinated with what was going on around him.
What does medicine say?
The internal organs and internal walls of the abdominal cavity are covered with a thin membrane – the peritoneum. Even minor damage to it during surgery, e.g. by touching, pulling or rubbing, contributes to the formation of adhesions. These are lamellar or planar, connective tissue formations resulting from inflammation, damage or irritation of the serous membranes.
– Surgical cutting of tissues, removal of a fragment or the entire organ, or even irritation of the peritoneum by rubbing it, initiates the healing process leading to the formation of a clot that closes the blood vessels, restoration of connections between tissues and regeneration of epithelium or scar formation. Many factors are involved in this process, such as: macrophages, fibroblasts, interleukins 1, cytokinins. As a consequence, the wound is covered with a layer of fibrin, closing the damaged tissue. This is a beneficial effect, sometimes saving our lives. At the same time, however, fibrin can cover adjacent tissues, causing the formation of abnormal connections that cause ailments, and sometimes life-threatening dysfunction, explains Andrzej Wojtyś, MD, PhD. Adhesions can therefore lead to the sticking of tissues with each other. Sometimes they do not cause any complications for many years and do not cause any discomfort. However, they can cause bothersome pain – chronic or recurrent, most often located in the lower abdomen.
A fresh wound can hurt
Monika’s mom kept telling her that nowadays an appendectomy is a cosmetic procedure and she shouldn’t worry about anything. She, however, did not feel well.
– When I was discharged from the hospital, I told the doctor that I was suffering from abdominal pains. I heard that a fresh wound has the right to hurt and that the discomfort will be less with time. Unfortunately, it did not happen, although I followed the recommendations. I did not carry anything heavy, I did not lift anything, I tried to save money, I took a leave of absence at work – says Monika.
40 days after the surgery, she returned to her normal lifestyle. She went to work, preparations for the wedding were in full swing again, her friend set another date for the hen party.
– I was just leaving work when a pain hit me so bad that I was unable to move. I stood in the hallway and couldn’t take a step, soaked in sweat and doubled over. A friend called an ambulance, I ended up in the emergency room. Olaf arrived after a few hours clearly dissatisfied. He suggested that my stomach ache from stress because I was probably afraid of getting married. Then I told him to go to hell, as long as he has so much to tell me – says Monika, resentful.
After that incident, her fiancé moved out of her apartment.
– At that time, I did not have the strength to wonder if he was offended. It hurt too much. I was at the surgeon, gynecologist, urologist, abdominal ultrasound, I had a lot of tests. After two weeks, the diagnosis was made – postoperative adhesions. I was given an antibiotic and a diastolic. I was to avoid painkillers. The surgeon explained to me that the pains should go away with time. He advised us to wait three months. If the pain is still very severe, you may need to operate again, she recalls.
What does medicine say?
Adhesions usually form within a week of surgery. When pain appears and causes it, it can be removed, but only during an additional treatment. Unfortunately, he is also at risk of developing further adhesions. The researchers showed in the studies that 79% of the patients (tested) with peritoneal adhesions had previously undergone surgery. The incidence of peritoneal adhesions increased with the extent of the procedure and the number of operations performed.
In health and in sickness
Monika and Olaf returned to each other after a few weeks. They met to discuss the future of their relationship and decided that one quarrel could not end it.
– When I think about it today, I come to the conclusion that we have succumbed to pressure from the family. Well, okay, I gave in. I should have listened to myself, not the words of my mother, who urged me to marry so much. Probably out of fear that I will become an old maid – says the girl and recalls how she struggled with recurring pain and fears for the next six months, whether Olaf would really prove to be a husband who would not leave his wife in “health and illness”.
– We postponed the date of the wedding, we decided to give ourselves more time. It seemed that everything was fine, but I saw that my ailments clearly irritated Olaf, and his painful expression made him irritated. He pretended it wasn’t, but I could clearly see the shrugs, the grimaces on my face, the indulgent looks. Once I talked about it with a friend who is a psychologist. She made me think about who in this relationship do I want to make happy more – myself, my fiancé, and maybe my parents? – he recalls.
Monika admits that unfortunately she did not follow her advice.
– I was afraid of loneliness. Besides, Olaf could be helpful, caring, he approached everything so sensibly. He once printed an entire article in a surgical journal for me, in which a doctor described the formation of adhesions after laparoscopic procedures to support fertility in women. We had a terrible fight again, because he did not understand that he was only scaring me with such behavior. And he supposedly wanted to help me figure out the problem in this way and prove that such things happen not only after the appendectomy. Then we started a discussion about fertility and children – Monika ironises and adds: – With time I realized that my fiancé is completely unable to cope with emotions.
What does medicine say?
Although appendectomy and gynecological surgery are the most common causes of postoperative adhesions in women, it is known that peritoneal adhesions also occur in patients after laparoscopic procedures supporting fertility. The consequences of postoperative adhesions can be very different.
Andrzej Wojtyś, MD, PhD mentions, inter alia:
• gastrointestinal dysfunction associated with narrowing of the intestine, which causes flatulence and pain;
• anatomical changes in the small pelvis that cause chronic or periodic pain and disorders of sexual intercourse (dyspareunia);
• infertility caused by adhesions in the small pelvis and inside the reproductive organ. However, the most serious consequence of adhesions is mechanical intestinal obstruction. In the case of this pathology, the mortality rate is 6-8%.
It has never hurt like this before
Olaf left Monika before she decided to surgically remove the adhesions. He calmly explained to her that the situation was too much for him, he preferred to have a smiling wife, not a grimacing wife, who was not sure if she would be able to give birth to him.
Monika remembers to this day that she was boiling with rage under the influence of his arguments. – The awl came out of the bag. I couldn’t believe I was so blinded. Fortunately, Olaf showed his true face before the wedding. I lost a year and a half because of him, not all my life – he argues.
However, the operation of the adhesions did not take place as planned. – One night I woke up with pain. It was different than usual – colic, rising. I had terrible attacks that lasted a few seconds. Then a break and so on again. I was tired from 3 am to 7 am. Red tea and antispasmodics did not help. In the morning, I called my friend from work and asked for a vacation on demand. At that time, I was still thinking soberly. When I started vomiting and my stomach ached all the time and it was very bloated, I asked my brother to take me to the hospital. I couldn’t get in the car on my own. I don’t think I’ve ever had such a pain before – he admits.
From a series of tests that were done to her the same day, she only remembers the strange x-ray of her abdomen in a standing position, which was supposed to indicate the level of fluid in the intestines. She remembers because she couldn’t stand anymore. When she went to the operating room, the surgeon explained to her that there was an intestinal obstruction, but he would try to fix it. However, Monika saw him as if through a fog.
What does medicine say?
Intestinal obstruction causes digestive disorders and disruptions of the food content – one of the most important life processes. Shortly after the bowel obstruction, increased peristaltic movement begins to remove the obstruction. In the lumen of the intestine, an increasing amount of food and gas accumulates above the obstruction. Intestinal pressure rises, the intestine becomes distended and its walls become thin. Bowel movements cease and absorption is inhibited. It is worth knowing that an adult secretes approximately 8-9 liters of digestive juices into the intestinal lumen daily, which are then reabsorbed by the mucosa of the end section of the small intestine. Under conditions of obstruction, intestinal juices remain in the intestine. Significant amounts of transudate fluid accumulate in the swollen intestinal wall and in the peritoneal cavity. Some of the body fluids are thus blocked and excluded from circulation. In the final stage of untreated intestinal obstruction, severe electrolyte disturbances, acidosis, extreme dehydration and cachexia, disturbance of consciousness and death occur.
You can’t be forcibly happy
Monika left the hospital after a month. She recovered surprisingly physically and mentally. The surgeon who operated on her explained that it was due to the laparoscopic technique. – I have found out for myself that everything happens faster and better after a laparoscopy: it hurts less, the intestines return to work faster, and a person returns to physical fitness. And the scar on the abdomen is smaller – she says and hopes that this time no adhesions will appear. So far, nothing hurts her and let it stay that way.
And Olaf? – It’s a closed chapter. Maybe in a moment I’ll be ready to open another one. So much for mine that I know that you cannot be happy by force – he says.
Worth knowing
How to reduce the formation of adhesions?
In order to reduce the risk of adhesions, more and more modern techniques, surgical tools (laser, harmonic knives, laparoscopy), pharmacological treatment (steroid anti-inflammatory, non-steroidal, antihistamine) and physical barriers are used. – The philosophy of using barriers to reduce postoperative adhesions is based on the belief that the separation of peritoneal surfaces with the use of various materials prevents adhesions in the early healing period – explains Andrzej Wojtyś, MD, PhD and lists the two most popular groups of physical barriers in gynecological operations:
• Insoluble Gore-Tex Surgical Membrane materials containing polyfluoroethylene. The network of holes in the material is very small, which prevents cells from growing into the material. The disadvantage of this method, however, is the fact that in most gynecological operations, especially in the treatment of infertility, it is necessary to repeatedly remove the non-absorbable membrane.
• Absorbable liquid and gel materials and membranes. They are left in the peritoneal cavity at the end of surgery. Fluids or gels facilitate the movement of organs within the abdominal cavity. For example, polymerized cellulose, polyethylene glycol, ferric iron salt of hyaluronic acid in the form of a gel film and pure hyaluronic acid in the form of a thick gel are applied, with which the surgical sites are covered. The gel layer prevents the formation of adhesions during the healing and regeneration of the epithelium. It stays on the application site for 7 days, after which it is absorbed.
Sometimes a suitably prepared beef or pig pericardium is also used.
Source: Let’s live longer
Text: Anna Niewiadomska