Not until I met the young lady on the operating table that I began to figure out what must have been going wrong. On inspection, the skin of the anterior abdominal wall had two surgical s cars. An appendectomy scar and a low midline scar possibly a relic of an abdominal surgical exploration. At that point I knew that I would not be performing any uterine surgery there. When eventually the medical director showed me the scan report and noticing the size of the uterus, I had no doubt in my mind that the uterus was not the cause of her predicament.
On opening up the abdomen, our suspicion was right. The abdomen was matted with what is generally referred to by caregivers as adhesion bands. These are mainly the result of or rather final product of inflammatory process in the abdomen. An assault to the body, be it trauma, infection or even radiation leads to the body initiating the process of countering the assault and neutralising the effect. This ultimately leads to the repair of damaged organs and healing. This process is known as inflammatory healing response. There are basically two types of healing. First is healing by primary intension. This is typically illustrated by the outcome of a clean uninfected surgical wound after seven days of infliction. Most times a thin line on the skin will be all that is seen.
On the other hand, healing by secondary intension is a feature of wide and complicated wounds and also when internal organs are affected by the assault. Classically this involves the formation of granulation tissue comprising of new blood vessels and different types of cells like fibroblasts and so on. The growth hormone is required for this rapidly proliferating tissue mass to thrive. Invariably, this granulation tissue ends up forming scars. A common example is what you see in a person who had suffered severe burns. In the abdomen the picture is a little bit different. Here the organ that mediates the inflammatory response is known as the omentum.
This organ is often referred to as the ‘police man’ of internal abdominal organs. It is made up of double sheet of peritoneum (abdominal envelop) folded on itself and in effect making it to be four layered from two omentum; greater and lesser respectively. Grossly, they drape like membranous fatty tissue with prominent blood vessels from the greater curvature of the stomach and Liver down to the pelvis. The omentum is a highly mobile and migratory organ. The functions of the omentum include fat storage, immunity, fighting infections and wound isolation.
Thus once there is any assault in the abdomen like an infection, the omentum is the organ that will respond by migrating to the site and wall off the lesion, in the process isolating it to prevent spread. The omentum also contains giant MACROPHAGES that are involved in engulfing pathogens and killing them. Most of the time, the resultant effect of this inflammatory response is formation of fibrous strands and bands in the abdominal cavity. There is always an omentum connection to these bands that can be attached to loops of bowel.
When this happens, loops of intestine can be forced to take unhealthy configurations. Firstly, an adhesion band can be so strong that it forms a bridge over intestinal loop in the process compressing it and narrowing its lumen. This ultimately would lead to intestinal obstruction. There are other variants like a loop of bowl herniating through a band and twisting around. This is usually a dangerous and life threatening condition known as volvulus. For a sessile organ like the intestine different shapes and form is the norm. When any of this complication occurs, the presenting symptom is severe abdominal pain that is intermittent in nature. This type of pain described as being colichy is common in most diseased luminal organs. In the case of the intestine, the intensity of the pain is worse when the peristaltic waves arrive at the site of the lesion.
This was the type of pains our index case had for one month before the surgical intervention. In her case, when we opened her up, we merely freed the bowel loops from the adhesions caused by previous abdominal assault and surgeries. The removal of the fibroid was a mere formality. No one thought of a hysterectomy at that point in time because there was absolutely no indication for it. Talk of missed diagnosis.
The diagnosis of adhesion bands is based on clinical history, especially surgery or trauma and a very high index of suspicion. The definitive diagnosis is made intra-operatively. Having said that much, it is expedient to carry out some investigations before surgical intervention if conservative management fails. Plain abdominal x-rays are often indicated in situations like this. It is useful in demonstrating the portion of the bowel affected and locate the exact position of the lesion before the surgeon goes in. This is usually mandatory in full-blown intestinal obstruction. Ultrasound scan of the abdomen is usually the first imaging investigation that is carried out. The truth of the matter is that the result would to a large extent depend on the experience of the Sonologists on duty when it comes to reading the bowel image on the monitor. There may be other incidental abdominal lesions encountered during scanning; the knowledge of which would be useful.
Blood counts, the state of Electrolytes and Urea should be determined if the facility is available. This is important especially having it at the back of one’s mind that fluid balance and dehydration can be a challenge in situations like this. But this should not in any way deter or delay surgical intervention. Once the patient has received enough fluid and making urine, he is good to go.