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Laparoscopic adhesiolysis for chronic pelvic pain

Dr.Shobhana Mohandas, Consultant gynaecologist and laparoscopic surgeon, Sun Medical and Research centre, Thrissur, Kerala, India.

Continous low grade pain is a very common condition found in middleaged women. Quite often it is due to some low grade infection which can be cured when treated meticulously. In some cases of chronic pelvic pain(Defined as persistent pain of more than 6 months duration), laparoscopy may be useful in evaluating  and curing the disease

 

 

 

How laparoscopy can be useful:

Sometimes pelvic infection leaves scars around the uterus and ovaries leading to pain. Release of painful  adhesions through the laparoscope could give relief. In the picture, the ovary is found stuck to the abdmominal wall. Every time the woman ovulates she would get severe pain due to this abnormal attachment. This could also give rise to painful menstrual periods. It may be difficult to detect this problem with any imaging modality except laparoscopy. Ultrasonography and CT scan may show no abnormality Sometimes, patients undergo hysterectomy for this condition, which is not necessary in all cases

ovarian adhesions

In patients with a disease called endometriosis , laparoscopy helps in diagnosing the condition .Resection of endometriosis from all surfaces, specially the  rectovaginal septal space could give relief.In the picture, the rectum is found adherent to the uterus and this adhesion is being released. endometriosisI

 

Sometimes pelvic pain is due to dilated veins near the uterus. These veins extend to the side of the ovary andsometimes may go upto the upper abdomen.. This is called pelvic venous congestion.  Patients get severe

pelvic congestion abdominal pain, menstrual pain, pain during intercourse,etc. Since they have many complaints, doctors sometimes also diagnose mental stress to be a cause of the problem. In the picture, the dilated blue veings can be seen by the side of the white ovaries and the long tubes.

 

Proper diagnosis of pelvic venous congestion can be made only from laparoscopy.  The other definintive mode of diagnosis of this condition,viz;venography is not done for this condition routinely in India. 

  After diagnosis proper medications could be given for cure.  If not properly diagnosed, many a time the woman may be subjected to hysterectomy and this would not cure the disease and the woman would end up undergoing a major surgery without getting cure for her illness.

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In some patients who have undergone major surgery like LSCS or hysterectomy the intestines may be adherent to the abdominal structures and may cause colicky pain when food passes through the adherent segment.   One such adhesion of intestine to the abdominal wall is seen in the picture. Laparoscopic release of these adhesions may give symptom relief. The author has done several cases of severe intestinal adhesions with good relief for the patients .

 

What it involves for the Patient:

Usually the patient is admitted the previous day, and an extensive bowel enema given .  She is asked to be on oral fluids from the previous day.  In case of minor adhesiolysis, she is allowed to go home the next day.  But if extensive intestinal adhesions , the patient is observed for 4-5 days to make sure the intestines are working properly.  Before surgery these patients are also warned about the possibility of intestinal injury which might lead to opening of the abdomen for bowel repair.

gynecology intestine

 

 

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