Jay A. Redan, MD
Determining the cause of abdominal and pelvic pain can be very difficult. Often the workup for abdominal pain, including endoscopy, radiologic tests, and physical examination, yields negative or inconclusive results, leaving the physician and patient with no diagnosis and a treatment consisting only of pain control.
Through the work of Harold Ellis, we know that over 90% of patients who undergo open abdominal surgery develop adhesions [1,2]. We also know from the recent Surgical and Clinical Adhesions Research (SCAR) Study in Scotland  that of the patients who underwent an open abdominal hysterectomy during their lifetime, 50% developed an adhesion-related complication requiring hospitalization. It is from studies such as these that we know adhesions are a very common cause of abdominal pathology and chronic pain.
The use of laparoscopy with photography and pathologic examination can often show the cause of the patient’s pain, and treatment can be performed then and there laparoscopically. Recently, many articles [4-7] have appeared in the literature showing the utility of laparoscopy for such a purpose. Additionally, a laparoscopy that is negative for pathologic findings can also prompt the primary care physician to explore other disciplines for treatment of patients with subjective chronic abdominal pain, sometimes psychological counseling being the treatment of choice.
We have devised guidelines to help with triage when patients have abdominal pain. Patients are first divided into 2 categories: prior surgery and no prior surgery. In patients with prior surgery, we further divide them into obstructed or not obstructed. Certainly, some patients who present with a bowel obstruction require surgery; those who are not obstructed and have had prior surgery should first undergo simple radiologic tests to evaluate for an underlying malignancy or other serious abdominal pathology. If any of the test results are positive, the patient proceeds to the appropriate treatment; however, negative test results would warrant a laparoscopic examination to evaluate for the presence of an adhesion-related disease.
Patients with no prior surgery first require radiologic evaluation of the abdomen and pelvis, endoscopy, and a medical workup. If the results of these tests are all negative, then a diagnostic laparoscopy should be performed to evaluate for any additional intraabdominal pathology.
Several questions now exist. Which adhesions cause pain? Do adhesions cause constipation, which in turn can lead to pain? When do adhesions lead to partial or complete small bowel obstruction? Will laparoscopic adhesiolysis cure pain? How long will adhesions remain asymptomatic, and how do health care providers differentiate people complaining of adhesion-related disease from people who are purely seeking pain medication? How do we design a study to assess the efficacy of laparoscopic adhesiolysis for pain? How much skill is needed to perform a successful adhesiolysis? Does an adhesiolysis procedure need to be performed by a surgeon and gynecologist?
First, which adhesions cause pain? The best way to answer this is with the use of patient directed laparoscopy as documented by Larry Demco . Advantages of this treatment modality are obvious; however, this clinical pathway is not suited for everyone. If a patient were able to tolerate direct laparoscopy under intravenous sedation, you would, no doubt, find the cause of that patient’s abdominal pain. However, many patients are not able to tolerate an “awake” laparoscopy, and often a patient’s adhesion disease is so extensive their treatment requires a long general anesthetic.
Adhesions are classified as abdominal wall, inter loop, and pelvic. Abdominal wall adhesions certainly cause pulling and tugging sensations due to the parietal peritoneal innervation. Most patients who have these adhesions lysed have immediate relief of their pain and almost certainly remain pain free unless these adhesions return.
Inter loop adhesions tend to cause more partial obstructive symptoms due to the kinking and twisting of the bowel.
Pelvic adhesions are most common in females and are correlated with dyspareunia and chronic pelvic pain in the posthysterectomy patient. Should there be adhesions to the adnexal structures or vaginal cuff, evaluation for endometriosis and ovarian remnants is most important.
The relationship of constipation and adhesions has long been debated. Many patients have a pseudo obstruction type or motility disorder. Most are female status posthysterectomy. Many have endometriosis relating to either an “N” or a “W”-shaped rectum. Subjectively, it is a common complaint among those with adhesion-related disease. Objectively, however, more study is required to definitively show that adhesions cause constipation [9,10].
Many patients who undergo a laparoscopy for abdominal pain, in the face of a workup with negative results, have a placebo effect for relief of their pain. This was emphasized in a current study by Swank et al [11,12] in which 50% of their patients who underwent a laparoscopy for pain in the control group had relief of their pain although they had undergone a procedure with no adhesiolysis. Additionally, patients who undergo a successful adhesiolysis may still have chronic pain; a neurological cause may be responsible for the patient’s continued pain, which may need to be addressed in conjunction with adhesiolysis .
Next, the area that certainly causes most questions among patients is “how long will the adhesions remain asymptomatic?” We do know that 90% of people who undergo an open procedure will have their adhesions return as documented by Harold Ellis . However, the recurrence rate of laparoscopic lysis of adhesions has not yet been widely established. Drs Swank [11,12], Reich [14,15], and Khaitain  all consistently reported that an average of 75% of their patients have a cure of their pain after a laparoscopic adhesiolysis.
Many formulations for adhesion prevention are commercially available and in trial for either intestinal adhesions or gynecologic/infertility adhesions. The caveat, however promising, is that results of trials for these products have a wide standard deviation in success and have not been consistently reproducible [17-21].
To provide adequate evidence-based medicine, the question of how to design a study to assess the efficacy of laparoscopic adhesiolysis for pain is quite difficult. To match patients in a prospective manner minimizing the variables from patient to patient while maintaining the same level of skill by the surgical operator and the ability to randomize the patients into either a controlled/no treatment group versus a “standardized” laparoscopic lysis of adhesions is virtually impossible. And finally, if not most importantly, to operate on a patient with pain and visible adhesions and to not perform an adhesiolysis because they have been randomized into this group would be at the least questionably unethical if not legally challengeable. Therefore, a prospective study, while valuable, is not feasible; we are forced to rely on retrospective data as our “standard of care.” Unfortunately, this adds an additional skewed variable in any summary of studies that are performed on this topic.
Finally, for any surgeon or gynecologist who has a patient with chronic abdominal pain, chronic pelvic pain, or both, where an adhesion related disorder is suspected, we ask that you keep in mind this minimally invasive diagnostic and most therapeutic tool as an option to offer these patients.
Address reprint requests to: Jay A. Redan, MD, c/o Celebration Health, 400 Celebration Pl, Ste B-200, Celebration, FL 34747. Tel: 407 303 4602, Fax: 407 303 4603, E-mail: [email protected]
Jay A. Redan has been performing laparoscopic and thoracoscopic procedures since the infancy of this specialty. Starting with laparoscopic cholecystectomy and diagnostic laparoscopy for trauma in 1989, he has participated in the growth of the specialty as it has evolved to a true general surgical specialty that now encompasses all abdominal (general and gynecologic) and thoracic surgery. Dr Redan has also been involved with the development of Hand-Assisted Laparoscopic Surgery (HALS) as well as teaching and preceptoring surgeons and students throughout the world.
An area of great interest has been the diagnosis and treatment of acute and chronic abdominal and pelvic pain. Dr Redan strongly believes in the liberal use of laparoscopy to provide patients with “photodiagnostics” that allow them to see exactly what the problem inside their abdomen is or is not.
Dr Redan is now the Medical Director of the Surgical Training Institute for General Surgery at Florida Hospital—Celebration Health.
Laparoscopic lysis of adhesions. Jay A. Redan, MD, and Mary Lou DePietro, LPN.
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