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ARD Education and Awareness

Abdominal/Pelvic Pain Can Occur After Surgery.
Abdominal/Pelvic pain can occur after surgery.  Post surgical pain can present shortly following your surgery, and usually resolves over the following days and weeks as you recover from that surgery. But some pain may linger for months or years following a surgical procedure. The question is, what is the source of this pain? 
In some cases, the answer is Adhesions!
    Adhesions are bands of scar tissue intra-abdominal and/or pelvic cavity that bind your internal organs together, causing them to stick to each other. The result of these bands of scar tissue can lead to: 
    Adhesion Related Disorder or ARD. 
    The symptoms of ARD include:
    • Chronic pain
    • Infertility 
    • Bowel obstruction
    • Gastro-esophageal reflux disease, (GERD)
    • Urinary Bladder dysfunction
    • Pain and difficulty having a bowel movement
    • Pain on movement such as: Walking, sitting or laying in certain positions.
    • Loss of Nutrients due to poor eating habits or loss of appetite.
    • Loss of employment due to lost work days
    • Loss of family and social life
    • Emotional Disorders such as: Depression, Thoughts of Suicide, Hopelessness
If you are experiencing pelvic pain, it’s important to see your doctor. Pain in the pelvic or abdominal area can be caused by a variety of conditions, some of which may be serious. Your doctor will be able to perform tests to determine the cause of your pain. Do not assume all pelvic or abdominal is caused by adhesion even if your post adhesiolysis, as adhesions do reform following surgery. 
It is important to ask for and allow diagnostic tests to rule out other sources of pathology as being the cause for your symptoms…while some adhesion do cause pain, not all adhesions cause pain and not all pain is caused by adhesions!
If all diagnostic tests result in negative findings, one cause of pain that your doctor might consider is adhesions, particularly if you have had abdominal or pelvic surgery. Adhesions are commonly associated with pelvic pain. In fact, an estimated 38 percent of women suffering from pelvic pain have adhesions. 

The better news is that there are things that your doctor can do to reduce the incidence post-operative adhesions – and maybe even prevent them altogether. Educate yourself to “Adhesion Related Disorder” as the informed patient can make informed decisions when you discuss your symptoms and medical care needs with your doctor.
            Always request and keep a personal file of all your medical interventions!

Adhesions Can Cause Pain:
Adhesions can cause pain by binding normally separate organs and tissues together - essentially “tying them down.” The stretching and pulling of everyday movements can irritate the nerves involved. Some adhesions can cause pain during intercourse. Ask your medical care provide to order an “ESR = Erythrocyte Sedimentation Rate” ‘ blood test for inflammatory reaction in your body. Inflammation at the adhesion attachment sites become agitated due to the pulling and tugging on the tissues of the attached organs. This inflammation creates pain and must be taken into consideration by the Doctor when treating the ARD sufferer for pain. 
While pelvic pain can be an obvious symptom of adhesions, there are other serious complications of which you should be aware. Two of the more common complications of adhesions are infertility and bowel obstruction. 

Adhesion can and do cause disabling pain and loss of productivity. You will want to resent substantiating information on this issue when you meet with your Doctor. 
Be prepared, be your own best Doctor!

Bowel obstruction:
Adhesion formation involving the bowel (intestine) is particularly common following hysterectomy. These adhesions occasionally they can cause the bowel to kink and not allow the passage of digested food. This causes a “back-up.” Bowel obstruction can occur shortly after surgery or many years later. Symptoms of bowel obstruction may include pain, nausea, and vomiting. Bowel obstruction is a serious illness and requires immediate medical attention. 
Even though the overall incidence of bowel obstruction is low, you should be aware of the possibility of its occurrence. If left untreated, obstruction can lead to serious complications, even death. Symptoms of bowel obstruction include: 

  • Abdominal pain
  • Nausea
  • Vomiting 
  • Diarrhea (early)
  • Constipation (late)
  • Fever 
You should talk to your doctor if you have any of these symptoms.

One of the more common non-surgical causes of pelvic pain is endometriosis.
If you have been trying unsuccessfully to conceive, you are probably searching for the cause. Your search may have led you to this site. It’s important to understand that there are many conditions that can cause infertility, and you should talk to your doctor to determine whether your situation requires medical attention.

Adhesions that form as a result of certain types of gynecologic surgery, especially tubal surgeries and myomectomies (surgery to remove fibroids), are a common cause of infertility. Adhesions can form between the ovaries, fallopian tubes or pelvic walls. 
These adhesions can block the passage of ovum (an egg) from the ovaries into and through the fallopian tubes. 
Adhesions around the fallopian tubes can also interfere with sperm transport to the ovum.

  • Ovarian Surgery
  • Surgical Treatment of Endometriosis
  • Myomectomy
  • Reconstructive Tubal Surgery 
The good news is that infertility due to pelvic adhesions can be successfully treated in approximately 40% to 60% of women. However, the surgical procedure, adhesiolysis, can often lead to more adhesions. The best way to reduce the chances of adhesions forming and/or reforming is for your surgeon to learn the best procedure used in the attempt to reduce adhesion formation. The more a surgeon practices the procedure, the more skilled he will become in performing it. As he develops his technique over time along with the use of an effective adhesion barrier, the better the results for improvement in the symptoms of the adhesion patient!

Talk to your doctor if you have pelvic pain of any kind.

Although adhesions often form after gynecologic surgery, they are not inevitable. And, even if adhesions do form, they usually don’t cause pain or other problems. 

Although there is no way to eliminate the risk of adhesions completely, there are steps your surgeon can take to reduce the likelihood of adhesion formation. The most effective methods of adhesion prevention involve meticulous surgical technique and the use of a physical barrier to separate tissue surfaces while they heal.

Surgeons have developed minimally invasive techniques such as the laparoscopy, that are designed to minimize trauma, blood loss, infection, and the introduction of foreign bodies, all of which can lead to inflammation and adhesion formation. Good surgical technique involves minimizing tissue handling, using delicate instruments, and keeping the tissues moist when they are exposed to the air.

While good surgical technique is important, but it is often not sufficient to prevent adhesions. There are also other preventive steps that can be taken:
Surgical techniques that can help decrease adhesion formation

Not simply the surgical procedure used, but in combination with these techniques and the lesser of invasive surgery, a laporoscopy, one has the best chance of adhesion reduction when these are used together in a surgery!

            • Achieve meticulous hemostasis 
            • Maintain vascularity 
            • Moisten tissues 
            • Avoid dry sponges 
            • Minimize tissue handling 
            • Use fine, non-reactive sutures 
            • Avoid peritoneal grafts 
            • Minimize foreign bodies 
Even though the most meticulous surgical and microsurgical techniques cannot eliminate the formation of adhesions, the following steps can be taken to reduce adhesion formation:
  • Achieve meticulous hemostasis: Inadequate hemostasis and the resultant fibrin deposition promote adhesion formation. 
  • Maintain vascularity: Limiting ischemia supports fibrinolysis. 
  • Moisten tissues: Frequent irrigation and the use of moist sponges prevent desiccation of tissue. Ringer's lactate or other irrigating solutions also eliminate any residual talc, lint, or blood clots, which may provide a nidus for a foreign body reaction, inflammation, and adhesion formation. 
  • Avoid dry sponges: Use of gauze and dry sponges should be avoided because they may damage the peritoneal surface and leave a foreign body behind. 
  • Minimize tissue handling: Manipulating tissue increases the possibility of vascular and tissue damage. When direct manipulation of the peritoneum is necessary, use either atraumatic instruments or fingers. In addition, cutting and coagulating should be kept to a minimum to reduce the possibility of trauma and maintain vascularity. 
  • Use fine, nonreactive sutures: To minimize foreign body reactions use the smallest size of suture composed of synthetic material. 
  • Avoid peritoneal grafts: Grafting increases the risk of peritoneal trauma while decreasing vascularity. 
  • Minimize foreign bodies: Foreign bodies may damage the peritoneal surface, lead to inflammation, and ultimately result in adhesion formation. 
If surgery is recommended for you, it's important to know what your options are and what questions to ask your primary-care physician and surgeon. If you learn all you can, you'll be sure that you're making the right decision. 

Jason Bodzin, M.D., F.A.C.S., director of the Inflammatory Bowel Disease (IBD) Institute at Sinai Hospital in Detroit, advises you to follow a four-step process: 

  • Examine your options. 
  • Talk to your surgeon. 
  • Talk to patients who have had the operation. 
  • Weigh all the factors in making your decision. 
Knowing What to Ask
Before consenting to surgery, the first question you should ask is: "Is this surgery necessary, or are there other medical options that I can try?" For instance, many people with IBD have avoided surgery by combining total parenteral nutrition (intravenous feeding) with medications. 6-MP, an immunomodulator drug, often successfully heals fistulas that once required surgery. 

You'll also want to know:

  • Are there other surgical options? 
  • What risks will I face by having the operation? 
  • How will the operation improve my condition? 
  • How long will my recovery take? 
  • Will I require medications following surgery? 
  • Whom do you recommend as a surgeon? As anesthesiologist? 
Choosing a Surgeon
Many sources can help you find a surgeon: 
  • Friends, relatives, neighbors 
  • Your primary-care physician 
  • American Board of Medical Specialties (ABMS): (800) 776-CERT. (The ABMS can tell you whether a surgeon is board-certified.) 
  • American College of Surgeons: (312) 664-4050, Ext. 391 
  • The American Society of Colon and Rectal Surgeons: (708) 290-9184 
  • Your local CCFA chapter 
  • Your health insurance carrier 
  • Your local hospital, or your state or county medical association -- all can provide lists of board-certified surgeons. 
Once you've compiled a list of two or three possible surgeons, ask the following questions about each one: 
  • Is he experienced with the particular operation you need? (This is particularly important if you are undergoing a fairly new procedure, such as an ileoanal anastomosis.) 
  • Does she treat many IBD patients? 
  • Is he affliated with the hospital you want to be in? 
  • Is she affiliated with a medical school or is she a member of its clinical faculty? 
You'll also want to know: 
  • Where the surgeon trained, what his specialization is, and whether he belongs to any professional organizations or has published any professional articles. (To get this information, ask the surgeon directly or go to the library.) 
  • Whether the hospital frequently performs your kind of surgery and whether the staff is well-versed in IBD.
Getting a Second Opinion:
It is always wise to get a second opinion. In fact, many insurance companies require it. Before seeking a second opinion, you may want to get copies of all your medical records. However, any physician can request these for you. 

If you receive conflicting opinions, visit a third surgeon or review the situation with your primary-care physician. Though this process can be frustrating and time-consuming, it will give you peace of mind.

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©Beverly J. Doucette. 2004 All rights reserved.