post-surgical adhesions:  abdominal wall -vs- abdominal cavity

“Adhesions are an almost inevitable outcome of surgery, and the problems that they cause are widespread and sometimes severe.  It has been said by some that adhesions are the single most common and costly problem related to surgery, and yet most people have not even heard the term.  This lack of awareness means that, excluding infertility, many doctors are unable or unwilling to tackle the problems of adhesions, many insurance companies are unwilling to pay for treatment and many patients are left in misery.” Dr. David Wiseman from Adhesions dot org

“The incidence of adhesions following abdominal surgery is cumulative with multiple surgeries and female gynecological surgeries giving a particularly high rate of adhesions.  In one study, autopsy investigations indicated a 90% incidence of adhesions in patients with multiple surgeries, 70% incidence of adhesions in patients with a gynecologic surgery, a 50% incidence of adhesions with appendectomy, and a greater than 20% incidence of adhesions in patients with no surgical history. Adhesions may occur as the result of tissue damage to the abdomen besides surgery, including traumatic injury, inflammatory disease, intraperitoneal chemotherapy, and radiation therapy.”  From Dr. Subhuti Dharmananda’s article called Abdominal Adhesions: Prevention and Treatment

I get numerous emails and questions on the message boards over at DESTROY CHRONIC PAIN that go something like this. 

“Hello Dr. Schierling, I’ve been reading your pages on Fascial Adhesions and the concept really resonates with me.  You see, I’ve been having pain ever since I had that [insert almost any abdominal or female surgery here] 22 years ago.  I am willing to make a trip to see you from [insert various states or countries here] if you think you can help me.  Sincerely, Johnette Q Public.” 

Although I certainly do help significant numbers of people with post-surgical Scar Tissue (they tend to be women; HERE is an example of a woman who struggled with post-surgical pain for the better part of two decades), there are some things you have to know in order to even hope to achieve a successful outcome. The Abdominal Wall has several layers.  Under the skin there’s a layer of subcutaneous fat, followed by two layers of FASCIA (Camper’s Fascia & Scarpa’s Fascia).  Then comes four layers of muscles that run in opposite directions to each other (the External Obliques, Internal Obliques, Rectus Abdominus, and Transverse Abdominus), each being separated from the other by a layer of Fascia.  This is followed by A VERY IMPORTANT LAYER OF FAT, under which lies the peritoneal wall (a membrane that covers the inner-most part of the Abdominal Wall, but also supports and surrounds the organs).  On the other side of the Peritoneum, you have the Abdominal Cavity (actually, you should probably think of the Peritoneum as the lining of the Abdominal Cavity).  

INSIDE OR OUTSIDE MAKES ALL THE DIFFERENCE IN THE WORLD

Because there are so many layers of the Abdominal Wall, there is plenty of opportunity for injury to occur (HERE, HERE, and HERE are a few of many).  Most of these — including those in the thorax or rib cage — can be successfully dealt with as well (HERE, HERE, and HERE).  But what about post-surgical SCAR TISSUE as opposed to Scar Tissue that was caused by an injury?  As long as the adhesion is in the Abdominal Wall, there is a good chance TISSUE REMODELING can help.  However, for those of you who are asking about adhesions caused by things like ENDOMETRIOSIS — problems that occur inside the Abdominal Cavity — things get much murkier. 

The first point to remember is that Inflammation always leads to a form of Scar Tissue that the medical community refers to as fibrosis (HERE).  Due to INFLAMMATION, tissues in the Abdominal Cavity such as the messentery (a membranous fold of connective tissue that attaches to the intestine to supply it with blood), the two ommentums (apron-like folds of peritoneum that hang from the stomach), and the peritoneum itself, can become Fibrotic.   In their natural state, these tissues should be slick / moist, supple, soft, and pliable.  Exposure to Inflammation can leave them dry, hard, and inflexible (see first link in this paragraph).  

As you might imagine, the resulting adhesions are essentially a “TETHERING” of your organs (intestines, bladder, uterus, ovaries, stomach, liver, etc, etc, etc) to each other as well as the surrounding tissues.  As you also might imagine, this can cause pain — pain that is frequently both severe and chronic.  As is the case with virtually all CHRONIC PAIN SYNDROMES, simply prescribing more MEDICATION is never the answer.  What’s the solution?  Doctors used to go back and surgically remove said Scar Tissue.  The problem is, in many (maybe even the majority of) cases, the Scar Tissue was caused by surgery in the first place.  Thus, even though the thought process for doing so was both logical and noble (SORT OF LIKE WHAT WE TALKED ABOUT IN YESTERDAY’S POST), the end result is that people often get worse.  It’s why this is not done nearly as frequently as it used to be.

“The treatment of adhesions is straight-forward. Patients undergo either laparoscopic or open surgery and the adhesions are cut by scalpel or electrical current (lyses). The problem is that adhesions have a tendency to reform.  Whether the adhesions are lysed by laparoscopic or open surgery, the inflammation caused by the process of cutting can result in recurrent adhesions.”  Cherry-picked from WebMD’s article by Dr. Bhupinder Anand, called Abdominal Adhesions: Symptoms & Treatment

“There is no way for you to prevent adhesions. This problem is one reason that doctors are cautious to recommend abdominal surgery only when it is necessary. If you are having abdominal surgery, your surgeon can minimize the risk of adhesions by using a gentle surgical technique and powder-free gloves.  Abdominal adhesions can be treated, but they can be a recurring problem. Because surgery is both the cause and the treatment, the problem can keep returning. For example, when surgery is done to remove an intestinal obstruction caused by adhesions, adhesions tend to form again and create a new obstruction”  Even though this quote came from Drugs dot com (a site devoted to giving you the lowdown on various medications), the authors did not offer any sort of drug therapy as a viable method of treating Abdominal Adhesions.

How can you tell whether the “Adhesion” is superficial (in the Abdominal Wall) or deep (in the Abdominal Cavity)?  Truth is, it can be extremely difficult — sometimes to the point of being virtually impossible.  In similar fashion to the test I came up with to help differentiate Piriformis Syndrome from Disc Problems (HERE), I created a simple test that you can do in the comfort of your own home to try and differentiate superficial adhesions from deep adhesions. 

Frequently, people with external Scar Tissue (Abdominal Wall) are going to be pulled forward into flexion sue to the tethering action of the Adhesion.  When I try and get these people into EXTENSION, they either cannot do it, or they balk because it hurts — typically at, or very close to, the area of the surgical incision.  While this scenario might prove true in some people who have internal Scar Tissue (Abdominal Cavity), this group typically has pain all the time.  They tend to not be able to get away from their pain by changing their posture or position, which the “Abdominal Wall” group typically can (activity will help them, but when they stop moving, they stiffen up and hurt in the problem area).  As you might gather, this test is not anywhere 100% accurate.  But then again, remember that unless your Internal Adhesions are severe enough to be causing a major structural issue such as bowel obstruction, diagnostic imaging will come back negative (HERE — see Dandi’s heart breaking comment at the bottom of the page).

Logically, the next question is, can anything be done for the pain if the problem is coming from inside the Abdominal Cavity?   As you can see from the quotes above, this is a serious problem.  And if you start looking at lists of things that doctors recommend for people with Post-Surgical Adhesions, it doesn’t take long to see how perplexing it really is (a great example is the Cleveland Clinic’s article, 4 Best Ways to Take Care of Abdominal Adhesions).  While following the advice of these sorts of articles is certainly not going to hurt you, there must be something better?  For many of you there is.

I would suggest to you that because it is so intimately related to Fibrosis (Scar Tissue), SOLVING THE UNDERLYING CAUSES OF INFLAMMATION is as good an option for dealing with Post-Surgical Adhesions as any available today.  And if you will make the effort to get your levels of Systemic Inflammation under control before you have surgery, all the better.  However, it’s never too late to deal with Inflammation, as it is the root of almost EVERY NON-GENETIC PROBLEM that can go wrong in your body. 

If you are one of the many people struggling with Post-Surgical Adhesions and have not tried ACUPUNCTURE or LOW LEVEL LASER THERAPY (you will have to use a Class IV as opposed to Class III because the later will not penetrate deep enough), they are options with practically zero side effects.  There are also specialized therapists / massage therapists who deal with this thing specifically.  For those of you for whom INFERTILITY is an issue (infertility can be related to Adhesions), you may want to look at this link as well.